⚠️ Teaching Case Note: This case has been de-identified and reconstructed for educational purposes. Clinical details reflect real surgical decision-making and outcomes. Patient identity is fully protected.
Three Years of Leg Pain, Walking Less Than 100 Metres — Decompressed and Fused Through Two 1 cm Incisions, Walking at Six Hours
He was 68 years old, Australian, with three years of low back pain and bilateral leg claudication that had progressively shortened his walking distance to under 100 metres. For the past two months, his left foot had been numb. MRI showed three-level lumbar stenosis, a Grade I L4 spondylolisthesis, and a spinal canal at L4–5 measuring 8 mm — against a normal of 12 mm or more. He had degenerative scoliosis with an 18-degree Cobb angle.
Open surgery — the conventional answer for multi-level stenosis with instability — would have required wide muscle stripping, significant blood loss, and a recovery measured in months. Dr. Yue Zhou's team at Changzheng Hospital, Naval Medical University, used a different approach: two 1 cm incisions, a continuous saline irrigation field, and a full-endoscopic unilateral biportal technique (UBE) to decompress the neural elements, place an interbody cage, and fix the construct with percutaneous screws.
Blood loss was under 50 mL. The patient walked at six hours. He was discharged on day three. At one year, his spinal alignment had normalized and his implants were stable.
The Anatomy: Three Levels, Instability, Scoliosis
Dynamic lumbar X-rays showed degenerative scoliosis with an 18-degree Cobb angle, L3–4 and L4–5 disc space narrowing, and Grade I anterior spondylolisthesis at L4 — indicating segmental instability that would not be adequately treated by decompression alone. Fusion was required.
MRI defined the neural compression. L3–4, L4–5, and L5–S1 all showed ligamentum flavum hypertrophy and disc protrusion. The critical level was L4–5: the spinal canal measured 8 mm in the sagittal diameter, the cauda equina was visibly compressed, and the left L5 nerve root was entrapped in the lateral recess and foramen. CT three-dimensional reconstruction confirmed severe facet joint hypertrophy with near-complete obliteration of the lateral recesses bilaterally at L4–5.
Clinical examination correlated precisely: left straight leg raise positive at 40 degrees, reduced sensation over the left lateral foot and dorsum, left hallux extension strength Grade IV. Intermittent claudication distance under 100 metres. JOA score 14 — moderate functional impairment.
The MDT Decision: Full-Endoscopic Fusion Over Open Surgery
The multidisciplinary team identified two competing considerations. The pathology required both decompression and fusion — the spondylolisthesis and scoliosis meant that decompression alone would leave the segment unstable and symptomatic. But the patient was 68, with hypertension and a prior abdominal surgery, and had specifically requested minimal recovery time and early return to activity — priorities that open posterior lumbar interbody fusion (PLIF) or transforaminal lumbar interbody fusion (TLIF) would not serve well. Open multi-level fusion in a patient of this age typically involves 300–600 mL blood loss, 5–7 days of hospitalization, and 3–6 months before return to light activity.
Dr. Zhou's team selected the unilateral biportal endoscopic (UBE) approach for L4–5 decompression and interbody fusion, supplemented by percutaneous pedicle screw fixation. The UBE system uses two separate portals — one for the endoscope, one for instruments — creating an independent working space filled with continuous saline irrigation. The saline medium provides a bloodless operative field through hydrostatic pressure, magnifies the anatomical detail under the endoscope, and allows simultaneous visualization and instrument manipulation that single-portal endoscopic systems cannot achieve.
The decision to address L4–5 as the primary surgical level — rather than all three stenotic levels — was based on the clinical correlation: the L4–5 compression was responsible for the dominant symptoms, the spondylolisthesis was at L4, and fusion at this level would also partially correct the scoliotic deformity through ligamentotaxis. L3–4 and L5–S1 would be managed conservatively and reassessed at follow-up.
The Operation: Decompression, Fusion, and Fixation Through Two Portals
Setup. General anesthesia. Prone position with the abdomen free — reducing intra-abdominal pressure and epidural venous engorgement, which is the primary source of bleeding in posterior spinal surgery. Two 1 cm incisions placed 1 cm lateral to the L4–5 interlaminar space on the left side, separated by approximately 2 cm vertically: the upper portal for the 30-degree endoscope, the lower portal for instruments.
Working space creation. Blunt soft tissue dissection established the two portals to the laminar surface. Continuous saline irrigation at controlled pressure maintained the working space, cleared the field of blood and debris, and created the hydrostatic environment that is the defining feature of UBE surgery. A self-retaining retractor held the portal open without requiring an assistant.
Decompression — the critical step. A piezoelectric ultrasonic bone scalpel (Piezo) was used under endoscopic visualization to remove the hypertrophied facet joint and ligamentum flavum. The Piezo device cuts bone without generating heat and without the vibrational energy of conventional drills — reducing the risk of inadvertent dural injury in a canal measuring 8 mm. The left L5 nerve root was fully decompressed from the lateral recess through the foramen. The herniated nucleus pulposus at L4–5 was removed. Dr. Zhou's emphasis throughout this phase was on maintaining a bloodless field — the saline irrigation pressure controlled epidural bleeding without bipolar coagulation, preserving the clarity of the neural anatomy at every step.
Endplate preparation and cage insertion. The L4 inferior endplate and L5 superior endplate cartilage were removed with endoscopic curettes, preserving the bony endplate to prevent cage subsidence. Trial sizers confirmed the appropriate cage dimensions. An 8 mm height PEEK interbody cage, packed with local autograft bone harvested during the decompression, was inserted through the working portal without enlarging the incision. Cage position was confirmed under C-arm fluoroscopy.
Percutaneous pedicle screw fixation. Under C-arm guidance, four percutaneous pedicle screws were placed at L4 and L5 bilaterally through stab incisions. Percutaneous rods were passed and the construct was locked — providing the segmental stability required for fusion while avoiding the paraspinal muscle dissection of open instrumentation.
Operative data: Total time 150 minutes. Estimated blood loss under 50 mL. No drain placed. No conversion to open surgery.
Recovery: Walking at Six Hours, Home on Day Three
The patient was awake in the recovery room with intact bilateral lower limb motor and sensory function. Left straight leg raise had improved from 40 degrees preoperatively to 70 degrees immediately postoperatively — confirming adequate neural decompression. The left foot numbness had partially resolved within hours of surgery.
Analgesia was managed with intraoperative local infiltration and postoperative oral NSAIDs. No opioids were required at any point. At six hours postoperatively, the patient stood and walked with a lumbar brace and walking frame. The urinary catheter was removed on postoperative day one. Normal diet resumed on day one. The patient was discharged on day three to a recovery hotel, with a structured physiotherapy program and written instructions in English.
No CSF leak. No wound infection. No deep vein thrombosis. No neurological deterioration.
Follow-Up: Fusion Confirmed, Scoliosis Corrected, Golf at Three Months
At one month: JOA score had improved from 14 to 24 — a clinically significant recovery. MRI confirmed the cage in correct position with complete neural decompression. The patient was walking independently with a lumbar brace.
At three months: X-ray showed early bridging bone formation at L4–5, meeting the radiological criteria for fusion. The Cobb angle had reduced from 18 degrees to 9 degrees — partial scoliosis correction achieved through the asymmetric cage placement and ligamentotaxis effect of the percutaneous instrumentation, without any osteotomy or long-segment fixation. The patient had resumed light swimming and golf practice.
At one year: spinal alignment was maintained, no implant loosening, no adjacent segment deterioration. Quality of life was self-reported as excellent. Claudication distance: unlimited.
Expert Commentary — Dr. Yue Zhou
"The conventional teaching is that multi-level stenosis with instability and scoliosis requires open surgery — wide exposure, long instrumentation, significant blood loss, and a prolonged recovery. That teaching was correct when the only available tools were open retractors and high-speed drills. It is no longer correct when you have a biportal endoscopic system, a piezoelectric bone scalpel, and a saline irrigation field that gives you better visualization than open surgery in a canal this narrow.
The UBE system's advantage over single-portal endoscopy is the independence of the visualization and working channels. With a single portal, every instrument movement disturbs the endoscope. With two portals, the endoscope is fixed and the instruments move freely — which is what you need when you are placing a cage and managing a nerve root simultaneously in an 8 mm canal.
The saline field is not a convenience — it is the operative environment. The hydrostatic pressure controls epidural venous bleeding without coagulation. The magnification under saline is superior to air. The continuous irrigation clears debris in real time. In a canal measuring 8 mm, the difference between a clear field and a bloody one is the difference between a safe decompression and a dural tear.
This patient walked at six hours. He played golf at three months. He came from Australia for this operation because it was not available to him at home at this level of complexity. That is what minimally invasive spine surgery should deliver — not just smaller incisions, but faster return to the life the patient came to us to recover."
About Dr. Yue Zhou
Dr. Yue Zhou is Chief of Spine Surgery at Changzheng Hospital, Naval Medical University, with expertise in minimally invasive spinal decompression, scoliosis correction, and cervical disc replacement. He has performed over 5,000 spinal procedures and is a national leader in endoscopic spine surgery techniques in China. Dr. Zhou regularly treats international patients seeking advanced spinal care in Shanghai and is recognized as a pioneer in the application of UBE technology to complex fusion cases.
How CMCS Supported This Patient
China Medical Concierge – Shanghai (CMCS) coordinated the full care pathway for this Australian patient: specialist matching and priority access to Dr. Zhou's team at Changzheng Hospital, multidisciplinary coordination across spine surgery, anesthesiology, and physiotherapy, full English-language communication throughout — including preoperative imaging review, surgical consent discussion covering the UBE technique and percutaneous fixation, and postoperative instruction in English — arrangement of a recovery hotel with physiotherapy support for the three days between discharge and international travel clearance, and remote follow-up coordination including MRI and X-ray scheduling at the patient's home institution with written reports provided in English for the treating team in Australia.
For international patients traveling to Shanghai for complex spinal surgery — where minimally invasive technique, rapid recovery, and seamless coordination between the Shanghai surgical team and the patient's home physicians determines the overall outcome — CMCS provides end-to-end support from initial imaging review to post-return follow-up.
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