Learning Curve Complications and Management Strategies in Unilateral Biportal Endoscopic Spine Surgery: A Case Series

This case series aims to highlight complications encountered during the early learning curve of unilateral biportal endoscopic (UBE) spine surgery, emphasizing challenges in managing pseudomeningoceles, operatively encountered conjoined nerve roots, and the unique complication of selective sensory deficits following an unexpected cranial direction of the C6 nerve root. The purpose is to emphasize the ongoing learning process required to optimize patient outcomes. Three cases were retrospectively reviewed. Case 1 describes a 36-year-old man with L5/S1 disc prolapse who underwent left UBE discectomy complicated by a major dural tear managed intraoperatively with glue but later required two additional surgeries for dural repair and continues to experience neuropathic pain. Case 2 involves a 35-year-old woman who underwent left UBE for L5/S1 discectomy and subsequently developed a small pseudomeningocele with intraoperatively encountered conjoined nerve roots, with persistent neuropathic pain despite conservative treatment. Case 3 involves a 45-year-old woman who underwent right C5/C6 UBE discectomy, during which an unexpected cranial orientation of the C6 nerve root was noted, resulting in postoperative selective sensory deficits that improved with conservative management over six weeks. This series focuses on complications encountered during the early phase of UBE surgery, where Case 1 illustrates the difficulty of managing large dural tears, Case 2 highlights the implications of conjoined nerve roots and pseudomeningocele-related neuropathic symptoms, and Case 3 describes atypical selective sensory deficits resulting from an aberrant C6 nerve root trajectory. An algorithmic representation of management strategies is included to assist decision-making for surgeons in the early stages of adopting UBE techniques. The findings underscore that the early learning curve of UBE spine surgery presents several unique challenges, particularly involving dural tears, anatomical variations such as conjoined nerve roots, and unexpected nerve root trajectories, and recognizing these issues while implementing appropriate management strategies can improve patient outcomes and support novice surgeons in refining their operative skills.