Does the floating technique for dural ossification in unilateral biportal endoscopic thoracic decompression offer comparable outcomes to resection? A propensity-matched analysis
Year: 2026
Type: article
Study design: Observational Study
Abstract: Thoracic ossification of the ligamentum flavum complicated by dural ossification carries a high risk of cerebrospinal fluid leakage during decompression. Whether the ossified dura should be resected or left as a floating island remains contested, and the choice is more consequential in unilateral biportal endoscopy, where watertight dural repair is technically difficult. We compared the two strategies in this setting. We retrospectively reviewed 131 consecutive patients treated for thoracic ossification of the ligamentum flavum at a single mini-invasive spinal surgery centre between January 2020 and December 2025. Thirty-nine patients with intraoperatively confirmed dural ossification treated by unilateral biportal endoscopy were identified (21 resection, 18 floating). 1:1 propensity score matching (caliper 0.2) on age, ossification area, spinal canal area, canal occupation ratio, and preoperative neurological score yielded 12 matched pairs. Perioperative metrics, intraoperative neuromonitoring, dural sac cross-sectional area on magnetic resonance imaging, modified Japanese Orthopaedic Association score, and Oswestry Disability Index were compared by t-test, Mann–Whitney U test, or Fisher’s exact test. Baseline characteristics were balanced after matching. The floating group had shorter operative time (2.57 ± 0.64 vs. 3.26 ± 0.69 h, P = 0.02) and a trend toward lower blood loss (30 vs. 55 mL, P = 0.07). No cerebrospinal fluid leakage occurred with the floating technique, compared with two cases (16.67%) requiring intraoperative repair after resection. Transient somatosensory evoked potential reduction was observed in two resection-group patients during dissection of the ossified dura, while no signal alerts occurred in the floating group. At three months, dural sac expansion (46% vs. 43%, P = 0.59), modified Japanese Orthopaedic Association recovery rate (31% vs. 33%, P = 0.98), and Oswestry Disability Index improvement (51% vs. 50%, P = 0.98) did not differ between groups. The floating technique matched resection in neurological recovery and dural sac re-expansion while shortening operative time and eliminating cerebrospinal fluid leakage. Because endoscopic dural repair is technically demanding, floating offers a safer and equally effective option for managing dural ossification in this setting. Long-term remodelling of the residual ossified island remains to be characterised.
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $3,090
OpenAlex ID: W7204942013
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