Clinical efficacy and safety of unilateral biportal endoscopy for thoracic ossification of ligamentum flavum: A systematic review.

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.