Unilateral Biportal Endoscopy (UBE): Why spine surgeons should make the leap and master the skills

1. Limited access to quality UBE training opportunities in their country. Hence, you should always aim for the best training centers around the globe and come back to start performing your UBE cases. You can even visualize yourself as a beacon of hope to newer spine surgeons in your country who are desiring to learn UBE and contemplate starting your own UBE training programs in future.
2. You may worry about the learning curve and the number of cases required to master UBE. The literature is divided on the same but based on my experience the number of cases required differs from surgeon to surgeon and is based on your previous experience in open and microscopic spine surgery. I may ruffle someone’s feathers here, but I think being trained in open and microscopic spine surgery is a must to be a good UBE spine surgeon.
3. You may also get frustrated about which type of endoscopic spine surgery to choose as there is lack of standardized consensus and protocols for learning by authorized associations. You may get into the perennial debate of full endoscopy versus UBE and how one is superior or better or less invasive than the other. These questions are better answered by discussing face to face with Key opinion leaders (KOLs).
4. You may worry about high stress levels during your initial cases. These types of frustrations can be minimized with optimal cadaver workshops, hands-on UBE training workshops and mentorship under experts. Also, understanding your own limitations and wisely choosing beginner cases at the start of your UBE career is the key point here.
5. You may suffer from peer pressure and suboptimal support from your reference group. Here, you will benefit immensely by attending dedicated endoscopic spine conferences where you meet like-minded spine surgeons and KOLs in respective specialty. Social media stands tall in the 21st century and you may benefit from LinkedIn and other dedicated UBE groups on Facebook, etc. 

1. Fear of failure: Fear that you may not be able to learn the technique owning to age (most common reason). Age is just a number and the more experienced in spine surgery you are the faster you will adopt to UBE. But the same doesn’t stand true for younger spine surgeons. Having a thorough open and microscopic MIS spine surgery experience is paramount before starting your UBE journey.
2. Fear of complications: Fear of complications in early learning curve is universal in all types of surgical procedures. UBE has a relatively better learning curve. On a lighter note, “the more you bleed in training, the less you bleed in war” and hence the role of optimal cadaveric training and hands on workshops before venturing into individual cases.
3. Fear of damage to professional reputation: Here again peer pressure and lack of support from professional community must be handled well.
4. Fear of legal issues: One may fear about complications and the legal repercussions that it may invite. These need to be checked at the national level and government health policies.
5. Fear of equipment malfunction: UBE or any endoscopic spine surgery uses specialized equipment’s like camera, arthroscope, shaver drill and radiofrequency plasma generator that we as spine surgeons are unaccustomed to. You feel the unfamiliarity of these equipment’s and they form the major hurdle in UBE learning curve. Despite using the same equipment’s multiple times, they may fail in your Nth case and then you may be handed over a completely different and unfamiliar endoscopy tower that you haven’t used before. Hence try to make yourself flexible while using different types of these equipment’s to ease your malfunction anxiety (More on these practical tips further).
6. Fear of impaired career progress: As spine surgeons you have been at the forefront of your career beginning from your pre-med to residency days and later fellowships. With UBE your career can get that long lost spark and help you propel forward in the career graph. 

1. Lack of hands-on experience: You may want to visit an UBE expert offering hands on training either in your country or outside.
2. Suboptimal Operating Room (OR) support team: You may find it worth to invest in teaching your OR team about the newer technique such as UBE. Training them and getting everyone on the same page is something you should look forward to. Trained OR support team may ease your anxiety and frustration regarding unfamiliar equipment malfunctioning.
3. Uncertain patient outcomes / Lack of conviction for UBE: You must visit a KOL in UBE or an expert who routinely performs these procedures. Endoscopic spine surgery is a philosophy that starts with careful pre-operative analysis of radiographs, CT scans and MRI scans followed by clinic-radiological correlation. The decision-making process in endoscopic spine surgery requires a specific temperament that takes some time to develop. The easiest and fastest way to develop this temperament is by shadowing an UBE expert and gaining regular insights from them. This process may take time for you but once the attitude of endoscopic spine surgery is developed your surgical decisions will change for the better.
4. Time constraints: You may have certain OR days and timing may be restricted. Performing initial UBE cases can be time consuming and hence keeping a timer in front of your eyes near the monitor will help to be time conscious.
5. Financial investment in UBE equipment: Having a UBE set and an arthroscopy tower with camera, light source, shaver drill and radiofrequency generator is a prerequisite for UBE. These can be bought by your institution but for almost 50 percent of us (based on data from LinkedIn poll) these expenses or investments are borne by the spine surgeons themselves. Hence adequate financial planning for the purchase and maintenance of these equipment’s should be considered.
6. Patient dissatisfaction: You should counsel the patient preoperatively regarding the need to convert an endoscopic spine surgery to open or microscopic spine surgery. This not only helps us avoid patient dissatisfaction but eases you off from unnecessary stress and performance anxiety. Now you can focus on doing the job well instead of doing the job through a particular surgical way.
7. Burnout and fatigue: These are real world problems that need to be addressed by quality training, timely appraisals and keeping one involved in academics and academic events.

Don’t feel bogged down by the previously enumerated issues! Our desires will keep us moving on the path to excellence in this surgical field.

1. Spine surgeons desire of comprehensive UBE training programs with cadaveric training, hands on training and then handholding by the mentor for a specified time duration.
2. They desire to advance their surgical career with skill acquisition.
3. You desire to be recognized at national or international level for your surgical expertise.
4. You desire for peer recognition and improved patient outcomes. 

1. After anesthesia always position your patient prone on a spine frame. The use of a spine frame helps in flexion of the lumbar spine and thus opens the inter-laminar window. A couple of millimeters of added opening will not matter much in open or microscopic spine surgery but it sure does make your life a lot easier in UBE. With UBE the added magnification and an opened interlaminar window aids in performing laminectomy and other surgical steps safely.
2. Try to wear a single glove in UBE. UBE is a fluid-medium surgery and outflow normal saline flows out of the working portal. While using radiofrequency probes in coagulation or ablation mode, the local temperature around the tissues may rise. This increase in temperature can be picked up far faster with a single glove prompting yourself to stop the usage of the probe and let some more fluid flow out to cool down the local water temperature around the neural elements.
3. There is a lot of variability in the commercial endoscopic spine surgery drapes that are available. Better to use stack of sterile towels to create a dam and a sterile plastic bag to collect the outflow saline all pasted together with an adhesive sterile drape. It is frustrating to get yourself wet in a cold OR and to make your surroundings a pool of water and hence you should be meticulous with water management.
4. Making the vertebral end plates squared and parallel is an important point but often neglected before marking and planning your surgical trajectories.
5. Using a T-shaped periosteal elevator or the blunt base of a number 7 handle helps you in the pre-endoscopy stage to prepare a working space. The gentle use of these instruments lifts the multifidus muscle and thus reduces the work of a radiofrequency probe and thus minimizing collateral muscle damage.
6. You should always triangulate your surgical instruments under C-arm fluoroscopy guidance in antero-posterior and lateral projections. This helps you to cross check the levels with MRI images and avoids wrong level surgery and prolonged surgical time.
7. A right-handed surgeon stands on the left side of a prone patient. The endoscopy tower with the screen, the C-arm monitor, and the c-arm screen come from the opposite side in front of your field of vision.
8. Shaver burrs are recommended in UBE Spine surgery for the following reasons: vast catalogue of disposable burrs with different sizes and shapes, hood to protect the underlying neural tissues, high torque and optimal RPM and the facility to attach suction tubing to the shaver handpiece. Foot-controlled shaver burrs are preferred.
9. Radiofrequency plasma equipment’s form an integral part of UBE. There is a lot of variation in the types of probes that are available in the market. Most frequently used probes are 90-degree ones that are foot pedal controlled. Using a hand-controlled probe is preferred by some spine surgeons therefore you must try different probes before you settle on a particular machine and probe. The coagulation and ablation settings vary from one machine to another and hence it would be a good idea to talk to your mentor regarding the same.
10. Another point that is commonly missed is to get the video recordings of your surgeries. I recommend you review these videos on the same evening and try to edit them with marked surgical step subtitles.
    
    This habit will serve two purposes: One you will focus on two questions:
    a. What went well in my UBE case?
    b. What could have been done better?
    
    Here, instead of focusing on other things with these focused questions we re-orient our thinking and mindset towards growth.
    
    Secondly, editing your videos and converting them to sizeable chunks of approximately 4–8-minute duration, you set yourself up for any future academic event where you can present these videos. 
    
    
11. Use a timer: It is advisable to use a timer while performing UBE cases. You may very well be lost looking at the screen into the beautiful world of spine endoscopy, coagulating every small bleeder and taking down every small tissue strand. These things may prolong the surgical orientation and hence a timer will make you time aware and relaxed.
12. Scope retractor: With full endoscopy you have something called as an endoscopy sheath that helps in soft tissue retraction and can double down as a nerve root retractor. In UBE it is advisable to use a scope retractor, a specialized instrument to aid in retraction. The scope retractor is one of the few essential and unique instruments required in UBE.
13. Angled curettes: Small angled curettes can help you to release the attachments of the yellow ligament and thus helping an en-bloc removal.
14. Hemostasis: Hemostasis is an important component of any spine surgery. But with UBE an important distinction arises as it is a fluid-medium surgery. With microscopic spine surgery or open surgery, we are trained to hold the suction in our non-dominant hand that aids you to suck the bleeding and also in some tissue retraction. In UBE the same thing is done by the arthroscopy sheath but instead of “Suction” we are “Washing” away the blood with a uniform flow of normal saline from the sheath. Hence UBE is not suctioning but washing away the bleeding.
15. Rotating Kerrison punches: These are not a pre-requisite but nice to have in your UBE set. Check them yourself in cadaver workshops before investing in these specialized punches.
16. Relaxation in OR with calm music can be helpful to some spine surgeons. This is dependent on you but having a supporting OR team is highly advantageous.
17. The orientation of UBE is like microscopic spine surgery. But a critical difference exists as microscopic spine orientation is three-dimensional, and UBE is two-dimensional and hence every surgical step needs to be double checked in the initial learning curve to avoid inadvertent complications.
18. Knowledge update: Like every spine surgery technique UBE demands what the Japanese call as “Kaizen” or continuous improvement. This can happen by reading textbooks on UBE, following literature, attending meetings and academic events focused on endoscopic spine surgery. If you are in an academic institution it will help to give topics on UBE to your residents and fellows to work on and to thus get the younger generation involved.
19. Practicing in an institution or in private practice never be shy to convert your UBE cases to microscopic or open spine surgery if need arises. It is a good idea to always carry your surgical loupe with you for UBE cases. Never commit that the surgery will be done through UBE technique as there are a lot of variables that are not in your control. It is a good idea to be well informed and comfortable with different equipment’s on the endoscopy tower.
20. Avoid unnecessary debates of whether full endoscopy is better, or UBE is better. Once you talk with KOL s and experts you should make up your mind as to which path you want to walk on. It is always better to know all forms of endoscopy but for the want of time, choose one and don’t look back.
21. When to start UBE? As previously emphasized UBE takes a level of spine surgical maturity before you venture into the technique. I advise everyone to transition from open spine surgery to microscopic spine surgery and then to UBE. One should be ready and competent to convert UBE to microscopic spine surgery in the face of a complication. Hence, the skill set of open spine and MIS gives you the apt surgical orientation and helps you to understand the relevant surgical anatomy in detail before UBE.