Clinical efficacy and safety of unilateral biportal endoscopy for thoracic ossification of ligamentum flavum - systematic review

Q: What clinical question does the review address for TOLF?

The review assesses the clinical efficacy and complications of unilateral biportal endoscopy (UBE) for treating thoracic ossification of the ligamentum flavum (TOLF), providing evidence to guide treatment decisions.

Q: What outcomes improved after UBE and what were the main safety concerns?

UBE was associated with significant improvements in leg pain, back pain, ODI, and JOA scores. The overall complication rate was 28%, mostly mild events; severe complications included dural tears and spinal cord injury (2.6% each).

Q: Why do the authors recommend more research?

Findings require validation because the sample size was limited and there was substantial heterogeneity among included studies, related in part to evolution of surgical techniques.

Sep 30, 2026

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A systematic review evaluates the clinical efficacy and complications of unilateral biportal endoscopy (UBE) for thoracic ossification of the ligamentum flavum (TOLF), aiming to support surgeons’ evidence-based decisions. Searches of PubMed, EMBASE, Cochrane Library, CNKI, Wanfang, and VIP were conducted through January 2025, including studies reporting outcomes for single or double-segment TOLF. Pain (VAS), function (ODI, JOA), and complications were pooled using random-effects models, with MCID applied. Six studies (n=77) showed significant improvements in leg and back pain, ODI, and JOA, with mostly mild complications. Preliminary evidence suggests UBE may enhance recovery and reduce perioperative morbidity despite limited sample size and heterogeneity.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages10

Reading Time25 min

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Objectives

Materials and methods

Results

Conclusion

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Joint Diseases and Related Surgery Jt Dis Relat Surg 2026;37(1):263-272 REVIEW Clinical efficacy and safety of unilateral biportal endoscopy for thoracic ossification of ligamentum flavum: A systematic review Jun Li, PhD1􀀬 , Linbo Jiang, MD2􀀬 , Ting Zhang, PhD3􀀬 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 Ossification of ligamentum flavum (OLF) is a pathological heterotopic ossification process where the fibrous tissue of the ligamentum flavum transforms into bony tissue, with its incidence usually increasing with age. Mechanical stress, genetic susceptibility, metabolism, obesity, and other factors may be associated with OLF. The majority of OLF cases occur in the thoracolumbar, which is associated with the greater mobility of this region and the lack of support from the thoracic cavity.[1] Thoracic OLF (TOLF) is often accompanied by thoracic spinal stenosis and thoracic myelopathy.[2-5] Early clinical symptoms are usually not obvious, while as the condition progresses, it may manifest as unilateral or bilateral lower limb | Received: April 20, 2025
Accepted: July 28, 2025
Published online: September 23, 2025
Correspondence: Ting Zhang, PhD. Department of General Surgery, Center of Obesity and Metabolic Diseases, Affiliated Hospital of Southwest Jiaotong University, the Third People’s Hospital of Chengdu, Chengdu, China .
E-mail: [zhangting@swjtu.edu.cn](zhangting@swjtu.edu.cn)
[Doi:](Doi: 10.52312/jdrs.2026.2108)[ 10.52312/jdrs.2026.2108](Doi: 10.52312/jdrs.2026.2108) | | --- | | 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 . | | ©2026 All right reserved by the Turkish Joint Diseases Foundation | This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes ([http://creativecommons.org/licenses/by-nc/4.0/](http://creativecommons.org/licenses/by-nc/4.0/)). 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 databasesup to January 2025. Inclusion criteria encompassed studies reporting UBE outcomes for single/double-segment TOLF. Data on pain (Visual Analog Scale [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

FAQs

What clinical question does the review address for TOLF?

The review assesses the clinical efficacy and complications of unilateral biportal endoscopy (UBE) for treating thoracic ossification of the ligamentum flavum (TOLF), providing evidence to guide treatment decisions.

Which databases and time frame were searched?

PubMed, EMBASE, Cochrane Library, CNKI, Wanfang, and VIP were searched up to January 2025.

What outcomes improved after UBE and what were the main safety concerns?

UBE was associated with significant improvements in leg pain, back pain, ODI, and JOA scores. The overall complication rate was 28%, mostly mild events; severe complications included dural tears and spinal cord injury (2.6% each).

Why do the authors recommend more research?

Findings require validation because the sample size was limited and there was substantial heterogeneity among included studies, related in part to evolution of surgical techniques.

Sep 30, 2026

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