Minimally invasive discectomy versus microdiscectomy/open discectomy for symptomatic lumbar disc herniation

Meta-analysis of percutaneous transforaminal endoscopic discectomy vs. fenestration discectomy in the treatment of lumbar disc herniation

OBJECTIVE

The aim of this study was to systematically review the efficacy of percutaneous transforaminal endoscopic discectomy (PTED) and fenestration discectomy (FD) in the treatment of lumbar disc herniation (LDH).

MATERIAL AND METHODS

We performed a systematic search in MEDLINE, EMBASE, PubMed, Web of Science, Cochrane databases, Chinese Biomedical Literature Database, CNKI, and Wanfang Data for all relevant studies. All statistical analyses wer performed using Review Manager version 5.3. Dichotomous data were calculated by odds ratio (OR) and continuous data were calculated by mean difference (MD) with 95% confidence intervals (CI).

RESULTS

A total of 17 articles with 1390 study subjects were included, with 733 patients in the PTED group and 657 patients in the FD group. The results of the meta-analysis showed that postoperative the visual analog scale (VAS) score (mean difference [MD] -0.13; 95% confidence interval [CI] -0.22 to -0.03; P = 0.009) and postoperative complications (MD 0.52; 95% CI 0.26 to 1.04; P = 0.06) showed no significant differences between the PTED group and the FD group, while the PTED group had significantly better results in operation time (MD 0.47; 95% CI -11.34 to 12.28; P = 0.94), length of incision (MD -3.74; 95% CI -4.28 to -3.19; P < 0.00001), amount of bleeding (MD -63.66, 95% CI -77.65 to -49.67; P < 0.00001), time of postoperative bed rest (MD -90.19; 95% CI -106.82 to -73.56; P < 0.00001), hospitalization time (MD -5.90; 95% CI -7.21 to -4.59; P < 0.00001), and postoperative Oswestry disability index (ODI) score (MD -0.59; 95% CI -1.11 to -0.08; P = 0.02) compared with the FD group.

CONCLUSION

The Percutaneous transforaminal endoscopic discectomy is associated with better postoperative ODI score, better results in length of incision, lower blood loss, shorter operation time, postoperative bed time and hospitalization time. The complications did not differ significantly between PTED and FD in the treatment of lumbar disc herniation. These findings provide evidence to support PTED is efficacious for LDH; however, scar repair of a ruptured anulus fibrosus needs a long time and the patients undergoing PTED should be advised to stay in bed for a long time even if the symptoms are markedly relieved. These results are not limited to randomized controlled trials and lack data about the long-term outcome.

A Systematic Review of Complications Following Minimally Invasive Spine Surgery Including Transforaminal Lumbar Interbody Fusion

PURPOSE OF REVIEW

To assess complications after minimally invasive spinal surgeries including transforaminal lumbar interbody fusion (MI-TLIF) by reviewing the most recent literature.

RECENT FINDINGS

Current literature demonstrates that minimally invasive surgery (MIS) in spine has improved clinical outcomes and reduced complications when compared with open spinal procedures. Recent studies describing MI-TLIF primarily for degenerative disk disease, spondylolisthesis, and vertebral canal stenosis cite over 89 discrete complications, with the most common being radiculitis (ranging from 2.8 to 57.1%), screw malposition (0.3-12.7%), and incidental durotomy (0.3-8.6%). Minimally invasive spine surgery has a distinct set of complications in comparison with other spinal procedures. These complications vary based on the exact MIS procedure and indication. The most frequently documented MI-TLIF complications in current published literature were radiculitis, screw malposition, and incidental durotomy.

Feasibility of Virtual Reality Combined with Isocentric Navigation in Transforaminal Percutaneous Endoscopic Discectomy: A Cadaver Study

OBJECTIVES

Transforaminal percutaneous endoscopic discectomy (TPED) is one of the most commonly used minimally invasive spine surgeries around the world. However, conventional surgical planning and intraoperative procedures for TPED have relied on surgeons' experience, which limits its standardization and popularization. Virtual reality (VR) is a novel technology for pre-surgical planning in various fields of medicine, while isocentric navigation can guide intraoperative procedures for TPED. The present study aimed to explore the feasibility of applying VR combined with isocentric navigation in TPED on cadavers.

METHODS

The surgical levels were L3 /L4 and L4 /L5 as well as L5 /S1 of both sides of each cadaver specimen. First, the surgeon manually conducted the above procedures on the left side of every specimen without preoperative simulation and isocentric navigation (Group A). Then the same surgeon conducted the VR simulation for surgical planning of the right side (Group B). After VR simulation, the same surgeon made the percutaneous punctures and placed the working channel on the right side of the specimen at all levels.

RESULTS

At the L3 /L4 level, the puncture-channel time was 11.36 ± 2.13 min in Group A and 11.29 ± 2.23 min in Group B (t = 0.097, P = 0.938). The exposure time was 17.21 ± 2.91 s in Group A and 14.64 ± 1.60 s in Group B (t = 2.534, P = 0.025). At the L4 /L5 level, the puncture-channel time was 13.86 ± 3.90 min in Group A and 11.93 ± 2.95 min in Group B (t = 2.291, P = 0.039). Exposure time was 20.64 ± 3.84 s in Group A and 16.43 ± 2.47 s in Group B (t = 6.118, P < 0.01). There were 7 patients undergoing foraminotomy in Group A and 3 patients undergoing foraminotomy in Group B (t = 2.280, P = 0.236). At the L5 /S1 level, the puncture-channel time was 18.21 ± 1.85 min in Group A and 15.71 ± 3.20 min in Group B (t = 2.476, P = 0.028). Exposure time was 26.07 ± 3.17 s in Group A and 22.50 ± 2.68 s in Group B (t = 2.980, P = 0.011). There were 14 patients receiving foraminotomy in Group A and 13 patients receiving foraminotomy in Group B (t = 1.000, P = 1.000).

CONCLUSIONS

Virtual reality combined with isocentric navigation is feasible in TPED. It enables precise surgical planning and improves intraoperative procedures, and has the potential for application in clinical practice.

A History of Endoscopic Lumbar Spine Surgery: What Have We Learnt?

The new development and finally the general acceptance of surgical techniques among the worldwide surgical community sometimes create fascinating stories. This is also true for the history of endoscopic lumbar spine surgery. In the last 100 years there was a “natural” evolution of surgical techniques with continuous improvement and “refinement” of lumbar decompression techniques towards less invasive operations with the final “endpoint” of microsurgery. However the application of percutaneous, image-guided, and endoscopic technologies has revolutionized minimally invasive surgery. This article describes the history of endoscopic lumbar spine surgery and its major milestones and protagonists which have helped to make endoscopic lumbar spine surgery “disruptive” minimally invasive surgical technology which has changed the world of lumbar decompression surgery.

“The past is the mother of the future”

Henri Cartier Bresson, French Photographer, 1908-2004

Recurrent lumbar disc herniation: Is there a correlation with the surgical technique? A multivariate analysis

Purpose

The recurrence of a lumbar disc herniation (LDH) is a common cause of poor outcome following lumbar discectomy. The aim of this study was to assess a potential relationship between the incidence of recurrent LDH and the surgical technique used. Furthermore, we tried to define the best surgical technique for the treatment of recurrent LDH to limit subsequent recurrences.

Materials and Methods

A retrospective study was conducted on 979 consecutive patients treated for LDH. A multivariate analysis tried to identify a possible correlation between (1) the surgical technique used to treat the primary LDH and its recurrence; (2) technique used to treat the recurrence of LDH and the second recurrence; and (3) incidence of recurrence and clinical outcome. Data were analyzed with the Pearson's Chi-square test for its significance.

Results

In 582 cases (59.4%), a discectomy was performed, while in 381 (40.6%), a herniectomy was undertaken. In 16 cases, a procedure marked as "other" was performed. Among all patients, 110 (11.2%) had a recurrence. Recurrent LDH was observed in 55 patients following discectomy (9.45%), in 45 following herniectomy (11.8%), and in 10 (62.5%) following other surgery. Our data showed that 90.5% of discectomies and 88.2% of the herniectomies had a good clinical outcome, whereas other surgeries presented a recurrence rate of 62.5% (Pearson's χ²< 0.001). No statistical differences were observed between discectomy or herniectomy, for the treatment of the recurrence, and the incidence for the second recurrences (P > 0.05). A significant statistical correlation emerged between the use of other techniques and the incidence for the second recurrences (P < 0.05).

Conclusions

The recurrence of an LDH is one of the most feared complications following surgery. Although the standard discectomy has been considered more protective toward the recurrence compared to herniectomy, our data suggest that there is no significant correlation between the surgical technique and the risk of LDH recurrence.

Percutaneous Endoscopic Lumbar Discectomy Assisted by O-Arm-Based Navigation Improves the Learning Curve

Objective

There is a steep learning curve with traditional percutaneous endoscopic lumbar discectomy (PELD). The aim of this study is to assess the safety and efficacy of PELD assisted by O-arm-based navigation for treating lumbar disc herniation (LDH).

Methods

From September of 2017 to January of 2018, 118 patients with symptomatic LDH were enrolled in the prospective cohort study. The patients undergoing PELD with O-arm-based navigation technique were defined as group A (58 cases), and those undergoing traditional X-ray fluoroscopy method were defined as group B (60 cases). We recorded the operation time, cannula placement time, radiation exposure time, visual analog scale (VAS), Oswestry Disability Index (ODI), and Macnab criteria score of the 2 groups.

Results

The average operation time (95.21 ± 19.05 mins) and the cannula placement time (36.38 ± 14.67 mins) in group A were significantly reduced compared with group B (operation time, 113.83 ± 22.01 mins, P<0.001; cannula placement time, 52.63 ± 17.94 mins, P<0.001). The learning curve of PELD in group A was steeper than that in group B and was lower in the relatively flat region of the end. There were significant differences of the clinical parameters at different time points (VAS of low back, P < 0.001; VAS of leg, P < 0.001; and ODI, P < 0.001). The VAS scores for low back pain and leg pain improved significantly in both groups after surgery and gradually improved as time went by. No serious complication was observed in any patients in either group.

Conclusion

The study indicated that PELD assisted by O-arm navigation is safe, accurate, and efficient for the treatment of lumbar intervertebral disc herniation. It reshaped the learning curve of PELD, reduced the difficulty of surgery, and minimized radiation exposure to surgeons. This study was registered at Chinese Clinical Trail Registry (Registration Number: ChiCTR1800019586).

Evidence Based Medicine Review of Posterior Thoracolumbar Minimally Invasive Technology

Background

Evaluate the current evidence in meta-analyses on posterior thoracolumbar minimally invasive surgery techniques and outcomes for degenerative conditions.

Methods

A systematic review of the literature from 1950 to 2015.

Results

The review of the literature yielded 34 meta-analysis studies evaluating posterior thoracolumbar minimally invasive techniques and outcomes for degenerative conditions. There were 11 studies included which investigated minimally invasive surgery (MIS) versus open posterior lumbar decompressions. There were 14 studies included which investigated MIS versus open posterior lumbar interbody fusions. Finally, there were 9 studies focused on navigation techniques and radiation safety within MIS procedures.

Conclusions

There are 34 meta-analysis studies evaluating minimally invasive to open thoracolumbar surgery for degenerative disease. The studies show a trend toward decreased estimated blood loss, decreased length of stay, decreased complications, similar fusion rates, improved accuracy, and decreased radiation when minimally invasive techniques are used.

Paraspinal muscle atrophy after posterior lumbar surgery with and without pedicle screw fixation with the classic technique

OBJECTIVES

Lumbar spine surgery causes a muscular injury during its approach that could worsen long-term postoperative functional results. This study aims to analyze the postoperative paraspinal atrophy associated with two types of intervention.

MATERIAL AND METHODS

Clinical records and lumbar magnetic resonance imaging were collected from a group of 41 patients, 20 underwent laminectomy with lumbar fixation due to lumbar spinal stenosis (fixation group) and another group of 21 underwent hemilaminectomy without fixation due to lumbar disc disease (non-fixation group). In which muscle atrophy was analyzed quantitatively.

RESULTS

We found a negative correlation between age and preoperative muscle, which was higher in those who underwent lumbar fixation (rho = -0.64 p = .002). We also found a positive correlation between preoperative muscle and postoperative atrophy (rho = 0.32 p = .041). In the age, sex and fixation adjusted multivariate linear regression model (R² = 0.31), laminectomy with fixation is attributed to 5.3% atrophy (IC95 1.4-9.5%, p = .017); preoperative musculature > 70% is attributed to atrophy of 13.8% (95% CI 5.5%-22%, p = .002). Age did not correlate with postoperative atrophy.

CONCLUSIONS

Paraspinal muscle atrophy after lumbar spinal surgery is greater if an extensive approach is performed such as complete laminectomy with bilateral facetectomy and transpedicular fixation. A greater previous musculature regardless of age, sex and type of surgery also predicts greater postoperative atrophy.

How I do it: percutaneous transforaminal endoscopic discectomy for lumbar disk herniation

BACKGROUND

Percutaneous transforaminal endoscopic discectomy (PTED) has emerged as a less invasive technique to treat symptomatic lumbar disk herniation (LDH). PTED is performed under local anesthesia with the advantage of immediate intraoperative feedback of the patient. In this paper, the technique is described as conducted in our hospital.

METHODS

PTED is performed under local anesthesia in prone position on thoracopelvic supports. The procedure is explained stepwise: e.g. marking, incision, introduction of the 18-gauge needle and guidewire to the superior articular process, introduction of the TomShidi needle and foraminotomy up to 9 mm, with subsequently removal of disk material through the endoscope. Scar size is around 8 mm.

CONCLUSION

PTED seems a promising alternative to conventional discectomy in patients with LDH and can be performed safely.

Contained Herniated Lumbar Disc: CT- and Fluoroscopy-Guided Automated Percutaneous Discectomy-A Revival

The combination of a new device and dual guidance (computed tomography [CT] and fluoroscopy) is similar to other percutaneous devices in achieving a mechanical decompression of the disc. The difference, however, is that the target of the decompression with the current technique is the herniated disc itself. The goal of this combined technique is to create a space, an "olive" around the probe, allowing a decrease in pressure inside the hernia. Percutaneous discectomy under combined CT and fluoroscopic guidance is a minimally invasive spine surgery that should be considered as an alternative to surgery in properly selected patients.

Minimally invasive spinal decompression surgery in diabetic patients: perioperative risks, complications and clinical outcomes compared with non-diabetic patients' cohort

BACKGROUND

Prior studies have documented an increased complication rate in diabetic patients undergoing spinal surgery. However, the impact of diabetes on the risk of postoperative complications and clinical outcome following minimally invasive spinal (MIS) decompression is not well understood.

OBJECTIVES

To compare complication rates and outcomes of MIS decompression in diabetic patients with a cohort of non-diabetic patients undergoing similar procedures.

METHODS

Medical records of 48 patients with diabetes and 151 control patients that underwent minimally invasive lumbar decompression between April 2009 and July 2014 at our institute were reviewed and compared. Past medical history, the American Society of Anesthesiologists score, perioperative mortality, complication and revision surgeries rates were analyzed. Patient outcomes included: the visual analog scale and the EQ-5D scores.

RESULTS

The mean age was 68.58 ± 11 years in the diabetic group and 51.7 ± 17.7 years in the control group. No major postoperative complications were recorded in either group. Both groups were statistically equivalent in their postoperative length of stay, minor complications and revision rates. Both groups showed significant improvement in their outcome scores following surgery.

CONCLUSIONS

Our results indicate that minimally invasive decompressive surgery is a safe and effective treatment for diabetic patients and does not pose an increased risk of complications. Future prospective studies are necessary to validate the specific advantages of the minimally invasive techniques in the diabetic population. These slides can be retrieved under Electronic Supplementary Material.

Isocentric Navigation for the Training of Percutaneous Endoscopic Transforaminal Discectomy: A Feasibility Study

Background

Percutaneous endoscopic transforaminal discectomy (PETD) is usually chosen for lumbar disc herniation due to its obvious advantages such as small incision and absence of nerve or muscular traction. However, learning PETD is a great challenge for inexperienced surgeons.

Objective

The study aimed to investigate whether isocentric navigation would be beneficial in PETD training.

Methods

A total of 117 inexperienced surgeons were trained with PETD at L2/3, L3/4, L4/5, and L5/S1 on the cadavers without (Group A n=58) or with (Group B n=59) isocentric navigation. Puncture times, fluoroscopy times, exposure time, and radiation dose were recorded and analyzed. Questionnaires were conducted before and after the training program.

Result

Isocentric navigation could improve young surgeons' satisfaction with the training program and decrease the puncture times, fluoroscopy times, exposure time, and radiation dose significantly (P<0.001).

Conclusion

Isocentric navigation contributes to the training of PETD and may improve its standardization, homogenization, and generalization.

[Operative treatment of degenerative diseases of the lumbar spine]

BACKGROUND

Degenerative diseases of the lumbar spine and associated lower back pain represent a major epidemiological and health-related economic challenge. A distinction is made between specific and unspecific lower back pain. In specific lower back pain lumbar disc herniation and spinal canal stenosis with or without associated segment instability are among the most frequent pathologies. Diverse conservative and operative strategies for treatment of these diseases are available.

OBJECTIVES

The aim of this article is to present an overview of current data and an evidence-based assessment of the possible forms of treatment.

MATERIAL AND METHODS

An extensive literature search was carried out via Medline plus an additional evaluation of the authors' personal experiences.

RESULTS

Conservative and surgical treatment represent efficient treatment options for degenerative diseases of the lumbar spine. Surgical treatment of lumbar disc herniation shows slight advantages compared to conservative treatment consisting of faster recovery of neurological deficits and a faster restitution of pain control. Surgical decompression is superior to conservative measures for the treatment of spinal canal stenosis and degenerative spondylolisthesis. In this scenario conservative treatment represents an important supporting measure for surgical treatment in order to improve the mobility of patients and the outcome of surgical treatment.

CONCLUSION

The treatment of specific lower back pain due to degenerative lumbar pathologies represents an interdisciplinary challenge, requiring both conservative and surgical treatment strategies in a synergistic treatment concept in order to achieve the best results for patients.

Comparing the Incidence of Index Level Fusion Following Minimally Invasive Versus Open Lumbar Microdiscectomy

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To determine the incidence of index level fusion following open or minimally invasive lumbar microdiscectomy.

METHODS

We conducted a retrospective review of 174 patients with a symptomatic single-level lumbar herniated nucleus pulposus who underwent microdiscectomy via a mini-open approach (MIS; 39) or through a minimally invasive dilator tube (135). Outcomes of interest included revision microdiscectomy and the ultimate need for index level fusion. Continuous variables were analyzed with independent sample t test, and χ² analysis was used for categorical data. A multivariate regression analysis was performed to identify predictive factors for patients that required index level fusion after lumbar microdiscectomy.

RESULTS

There was no difference in patient demographics in the open and MIS groups aside from length of follow-up (60.4 vs 40.03 months, P < .0001) and body mass index (24.72 vs 27.21, P = .03). The rate of revision microdiscectomy was not statistically significant between open and MIS approaches (10.3% vs 10.4%, P = .90). The rate of patients who ultimately required index level fusion approached significance, but was not statistically different between open and MIS approaches (10.3% vs 4.4%, P = .17). Multivariate regression analysis indicated that the need for eventual index level fusion after lumbar microdiscectomy was statistically predicted in smokers and those patients who underwent revision microdiscectomy (P < .05) in both open and MIS groups.

CONCLUSIONS

Our results suggest a low likelihood of patients ultimately requiring fusion following microdiscectomy with predictors including smoking status and a history of revision microdiscectomy.

The Recent Trend in Diagnosis and Treatment of Chronic Low Back Pain

INTRODUCTION

Development of evidence-based medicine has made a big change in diagnosis and treatment of chronic low back pain. The recent trend is assessed through a review of literature.

METHODS

The articles published in these 10 years are reviewed, and important points are examined.

RESULTS

In diagnosis, challenges for history taking and limit of imaging or clinical guidelines are revealed. In treatment, cognitive behavioral treatment and exercises are proved effective. Sleep disturbance has recently attracted attention as a factor associated with low back pain. Cost-effectiveness of diagnosis and treatment modalities has come to be emphasized.

CONCLUSIONS

Diagnosis and treatment of chronic low back pain have been significantly changing. Multidisciplinary and multidimensional approach is essential. Chronic low back pain should be treated as a total pain, not a local pain.

Multi-level spine endoscopy: A review of available evidence and case report

In the last ten years, there has been an exponential increase in endoscopic spinal surgery practice.

With improvements in equipment quality and the availability of high definition camera systems, cervical endoscopic disc resection is now a viable alternative to anterior cervical decompression and fusion (ACDF) or disc arthroplasty for the treatment of disc prolapse and low grade stenosis.

Based on the current literature, there is now strong evidence to support the use of transforaminal endoscopic approaches for the treatment of thoracic disc prolapse.

There is now level I evidence to show that outcomes following transforaminal endoscopic discectomy (TED) are at least equivalent to those after open microdiscectomy, with an expected shorter operating time, lesser requirement for analgesia, reduced duration of post-operative disability, more rapid rehabilitation and lower costs of care. However, it should be recognised that there is a significant learning curve for TED.

New endoscopic techniques with interlaminar approaches allow the decompression of central and lateral recess stenosis. Future developments will facilitate vision and access to the spine with 3D imaging and robotics at the forefront.

We present a case report of whole spine endoscopic decompression to illustrate the potential of endoscopic surgery at all spinal levels.

Cite this article: EFORT Open Rev 2017;2:317-323. DOI: 10.1302/2058-5241.2.160087

Alcohol consumption for simulated driving performance: A systematic review

PURPOSE

Alcohol consumption can lead to risky driving and increase the frequency of traffic accidents, injuries and mortalities. The main purpose of our study was to compare simulated driving performance between two groups of drivers, one consumed alcohol and the other not consumed, using a systematic review.

METHODS

In this systematic review, electronic resources and databases including Medline via Ovid SP, EMBASE via Ovid SP, PsycINFO via Ovid SP, PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINHAL) via EBSCOhost were comprehensively and systematically searched. The randomized controlled clinical trials that compared simulated driving performance between two groups of drivers, one consumed alcohol and the other not consumed, were included. Lane position standard deviation (LPSD), mean of lane position deviation (MLPD), speed, mean of speed deviation (MSD), standard deviation of speed deviation (SDSD), number of accidents (NA) and line crossing (LC) were considered as the main parameters evaluating outcomes. After title and abstract screening, the articles were enrolled for data extraction and they were evaluated for risk of biases.

RESULTS

Thirteen papers were included in our qualitative synthesis. All included papers were classified as high risk of biases. Alcohol consumption mostly deteriorated the following performance outcomes in descending order: SDSD, LPSD, speed, MLPD, LC and NA. Our systematic review had troublesome heterogeneity.

CONCLUSION

Alcohol consumption may decrease simulated driving performance in alcohol consumed people compared with non-alcohol consumed people via changes in SDSD, LPSD, speed, MLPD, LC and NA. More well-designed randomized controlled clinical trials are recommended.

Significant reduction of fluoroscopy repetition with lumbar localization system in minimally invasive spine surgery: A prospective study

The conventional location methods for minimally invasive spinal surgery (MISS) were mainly based on repeated fluoroscopy in a trial-and-error manner preoperatively and intraoperatively. Localization system mainly consisted of preoperative applied radiopaque frame and intraoperative guiding device, which has the potential to minimize fluoroscopy repetition in MISS. The study aimed to evaluate the efficacy of a novel lumbar localization system in reducing radiation exposure to patients.Included patients underwent minimally invasive transforaminal lumbar interbody fusion (MISTLIF) or percutaneous transforaminal endoscopic discectomy (PTED). Patients treated with novel localization system were regarded as Group A, and patients treated without novel localization system were regarded as Group B.For PTED, The estimated effective dose was 0.41 ± 0.13 mSv in Group A and 0.57 ± 0.14 mSv in Group B (P < .001); the fluoroscopy exposure time of PTED was 22.18 ± 7.30 seconds in Group A and 30.53 ± 7.56 seconds in Group B (P < .001); The estimated cancer risk of radiation exposure was 22.68 ± 7.38 (10) in Group A and 31.20 ± 7.96 (10) in Group B (P < .001). For MISTLIF, the estimated effective dose was 0.45 ± 0.09 mSv in Group A and 0.58 ± 0.09 mSv in Group B (P < .001); The fluoroscopy exposure time was 25.41 ± 5.52 seconds in Group A and 32.82 ± 5.03 seconds in Group B (P < .001); The estimated cancer risk was 24.90 ± 5.15 (10) in Group A and 31.96 ± 5.04 (10) in Group B (P < .001). There were also significant differences in localization time and operation time between the 2 groups either for MISTLIF or PTED.The lumbar localization system could be a potential protection strategy for minimizing radiation hazards.

Risk Factors for Postoperative Pain Intensity in Patients Undergoing Lumbar Disc Surgery: A Systematic Review

OBJECTIVES

Pain relief has been shown to be the most frequently reported goal by patients undergoing lumbar disc surgery. There is a lack of systematic research investigating the course of postsurgical pain intensity and factors associated with postsurgical pain. This systematic review focuses on pain, the most prevalent symptom of a herniated disc as the primary outcome parameter. The aims of this review were (1) to examine how pain intensity changes over time in patients undergoing surgery for a lumbar herniated disc and (2) to identify socio-demographic, medical, occupational and psychological factors associated with pain intensity.

METHODS

Selection criteria were developed and search terms defined. The initial literature search was conducted in April 2015 and involved the following databases: Web of Science, Pubmed, PsycInfo and Pubpsych. The course of pain intensity and associated factors were analysed over the short-term (≤ 3 months after surgery), medium-term (> 3 months and < 12 months after surgery) and long-term (≥ 12 months after surgery).

RESULTS

From 371 abstracts, 85 full-text articles were reviewed, of which 21 studies were included. Visual analogue scales indicated that surgery helped the majority of patients experience significantly less pain. Recovery from disc surgery mainly occurred within the short-term period and later changes of pain intensity were minor. Postsurgical back and leg pain was predominantly associated with depression and disability. Preliminary positive evidence was found for somatization and mental well-being.

CONCLUSIONS

Patients scheduled for lumbar disc surgery should be selected carefully and need to be treated in a multimodal setting including psychological support.

Full-endoscopic versus micro-endoscopic and open discectomy: A systematic review and meta-analysis of outcomes and complications

OBJECTIVES

The purpose of this study was to systematically compare the effectiveness and safety of full-endoscopic discectomy (FED) and micro-endoscopic discectomy (MED) with open discectomy (OD) for the treatment of symptomatic lumbar disc herniation.

METHODS

Electronic searches were performed using six databases from their inception to February 2016, identifying all relevant randomized controlled trials and comparative observational studies comparing either FED or MED with OD. Data were extracted and analyzed according to predefined clinical endpoints.

RESULTS

Twenty three studies were selected for analysis, including 421 FED, 6914 MED, and 21,152 OD cases. No significant difference was found between FED and OD in regards to postoperative visual analog scale (VAS) leg pain scores (WMD 0.03, P=0.93). Similar results were obtained for MED vs OD (WMD 0.09, P=0.18). In terms of postoperative Oswestry disability index (ODI), both FED and MED were similar to OD (WMD -2.60, P=0.32 and WMD -1.00, P=0.21, respectively). FED had a significantly shorter operative duration compared to OD (54.6 vs 102.6min, P=0.0001). MED alone and endoscopic approaches overall (including MED and FED) demonstrated significantly lower estimated blood loss (44.3 vs 194.4mL, P=0.03 and 38.2 vs 203.5mL, respectively, both p<0.05). FED alone demonstrated a trend towards lower estimated blood loss in comparison to OD (3.3 vs 244.9mL, P=0.07). No difference was found in overall complications, recurrence or reoperation rates, dural tears, root injury, wound infections, and spondylodiscitis between FED vs OD, or MED vs OD.

CONCLUSIONS

Based on this meta-analysis, FED and MED appear to be safe and efficacious alternatives to traditional approaches, but these results require further investigation and validation by prospective randomized studies.

A randomised controlled trial of transforaminal endoscopic discectomy vs microdiscectomy

PURPOSE

Transforaminal endoscopic discectomy (TED) minimises paraspinal muscle damage. The aim of this trial was to compare clinical outcomes of TED to Microdiscectomy (Micro).

METHODS

143 patients, age 25-70 years and <115 kg, with single level lumbar prolapse and radiculopathy, were recruited and randomised. 70 received TED under conscious sedation and 70 Micro under general anaesthesia. Oswestry Disability Index (ODI), visual analogue scores (VAS) of back and leg pain, and Short Form Health Survey indices (SF-36) were measured preoperatively and at 3, 12 and 24 months.

RESULTS

All outcome measures improved significantly in both groups (p < 0.001). Affected side leg pain was lower in the TED group at 2 years (1.9 ± 2.6 vs 3.5 ± 3.1, p = 0.002). Hospital stay was shorter following TED (0.7 ± 0.7 vs 1.4 ± 1.3 days, p < 0.001). Two Micro patients and five TED patients required revision giving a relative risk of revision for TED of 2.62 (95% CI 0.49-14.0).

CONCLUSIONS

Functional improvements were maintained at 2 years in both groups with less ongoing sciatica after TED. A greater revision rate after TED was offset by a more rapid recovery.

Sedation for Percutaneous Endoscopic Lumbar Discectomy

Although anesthetic requirements for minimally invasive neurosurgical techniques have been described in detail and applied successfully since the early 2000s, most of the literature on this subject has dealt with cranial cases that were operated on in the supine or sitting positions. However, spinal surgery has also used minimally invasive techniques that were performed in prone position for more than 30 years to date. Although procedures in both these neurosurgical techniques require the patient to be awake for a certain period of time, the main surgical difference with minimally invasive spinal surgery is that the patients are in the prone position, which may result in increased requirement of airway management because of deep sedation. In addition, although minimally invasive spinal surgery progresses slowly and different techniques are used with no agreement on the terminology used to describe these techniques thus far, the anesthetist needs to understand the surgical and anesthetic requirements for each type of intervention in order to take necessary precautions. This paper reviews the literature on this topic and discusses the anesthetic necessities for percutaneous endoscopic laser surgery.

Does local lavage influence functional recovery during lumber discectomy of disc herniation?: One year's systematic follow-up of 410 patients

Lumbar disc herniation (LDH) is a common disease and lumbar discectomy is the most common surgical procedure carried out for patients with low back pain and leg symptoms. Although most researchers are focusing on the surgical techniques during operation, the aim of this study is to evaluate the effect of local intervertebral lavage during microdiscectomy.In this retrospective study, 410 patients were operated on by microdiscectomy for LDH during 2011 to 2014. Retrospectively, 213 of them (group A) accepted local intervertebral irrigation with saline water before wound closure and 197 patients (group B) only had their operative field irrigated with saline water. Systematic records of visual analog scores (VAS), Oswestry disability Index (ODI) questionnaire scale scores, use of analgesia, and hospital length of stay were done after hospitalization.The majority (80.49%) of the cases were diagnosed with lumber herniation at the levels of L4/5 and L5/S1. Fifty-one patients had herniations at 2 levels. There were significant decreases of VAS scores and ODI in both groups between preoperation and postoperation of different time points. VAS scores decreased more in group A than group B at early stage of postoperation follow-up. However, there were no statistically significant differences between 2 groups in using analgesia, VAS and ODI up to 1 month of follow-up.Microdiscectomy for LDH offers a marked improvement in back and radicular pain. Local irrigation of herniated lumber disc area could relief dick herniation-derived low back pain and leg radicular pain at early stage of post-operation. However, the pain relief of this intervention was not noticeable for a long period.

[Surgical treatment of lumbar disc herniation]

OBJECTIVE

Herniated disc tissue removal to decompress the spinal nerve/cauda equina. Minimization of iatrogenic trauma and associated injuries.

INDICATIONS

Conservative treatment did not sufficiently improve clinical symptoms. This is true for progressive or persisting neurological deficits, as well as for persisting pain which alters the quality of the patient`s life. Results of surgery are strongly dependent on the preoperative duration of symptoms. Paramount is the "timing" of surgery: poorer surgical results associated with increasing preoperative duration of symptoms.

CONTRAINDICATIONS

Conservative treatment modalities have not been exhausted.

SURGICAL TECHNIQUES

There are 2 technologies (endoscopic/microsurgical) and 5 different approach strategies (endoscopic: interlaminar, transforaminal; microsurgical: interlaminar, translaminar, extraforaminal), whereby the choice is determined by morphology and location of the herniated disc. All techniques are minimally invasive and lead to comparable clinical results.

POSTOPERATIVE MANAGEMENT

For all techniques, patients are mobilized early. Light sports activities allowed after 2 weeks and return to work after about 4 weeks.

RESULTS

Good clinical outcomes in meta-analyses/large case series are between 80-95 %.

Open discectomy vs microdiscectomy for lumbar disc herniation - a protocol for a pragmatic comparative effectiveness study

Introduction: 

Since the introduction of lumbar microdiscectomy in the 1970’s, many studies have attempted to compare the effectiveness of this method with that of standard open discectomy with conflicting results. This observational study is designed to compare the relative effectiveness of microdiscectomy (MD) with open discectomy (OD) for treating lumbar disc herniation, -within a large cohort, recruited from daily clinical practice.

Methods and analysis:  

This study will include patients registered in the Norwegian Registry for Spine Surgery (NORspine). This clinical registry collects prospective data, including preoperative and postoperative outcome measures as well as individual and demographic parameters. The primary outcome is change in Oswestry disability index between baseline and 12 months after surgery. Secondary outcome measures are improvement of leg pain and changes in health related quality of life measured by the Euro-Qol-5D between baseline and 12 months after surgery, complications to surgery, duration of surgical procedures and length of hospital stay.

Minimally invasive lumbar decompression-the surgical learning curve

BACKGROUND CONTEXT

Minimally invasive spine surgery (MIS) procedures carry an inherently difficult learning curve based upon anecdotal evidence. Few studies have investigated the surgeon's learning curve for MIS lumbar laminectomy or laminotomy with or without discectomy.

PURPOSE

To characterize the learning curve of a 1- or 2-level MIS lumbar decompression (LD) based on perioperative and postoperative parameters .

STUDY DESIGN/SETTING

Retrospective analysis of a prospectively maintained registry was used for this study.

PATIENT SAMPLE

There were 228 consecutive patients who underwent a primary 1- or 2-level MIS LD by a single surgeon for degenerative spinal pathology from 2009 to 2014. From 2005 to 2006, 50 patients underwent 1- or 2-level open LD consecutively.

OUTCOME MEASURES

Perioperative and postoperative outcomes (complications, visual analogue scale [VAS] scores, reoperations) were the outcome measures for this study.

METHODS

Patients were stratified into first and second groups as determined by the case number at which the procedural time reached a plateau. Demographics, comorbidity, pain scores, and surgical outcomes were compared between the first 50 patients and the subsequent 178 patients. The secondary analysis compared the surgical outcomes between the initial 50 MIS and 50 open LD patients. No funds were received in support of this work.

RESULTS

The initial cohort was older with a higher comorbidity burden (p<.05). However, body mass index, gender, smoking status, and ethnicity did not differ between cohorts. The initial cohort incurred a greater procedural time (p<.001) and longer length of hospitalization (p<.05) than the second cohort. Estimated blood loss (EBL), pain scores, complication rates, recurrent herniation rates, and reoperation rates were similar between groups. In the secondary analysis, the open LD patients demonstrated greater procedural time, higher EBL, and longer length of hospital stay than the MIS patients. However, the reoperation rate and 30-day readmission rate were not different between the MIS and open patients.

CONCLUSIONS

Continued surgical experience was associated with a reduced operative time, shorter length of hospitalization, and similar blood loss following an MIS LD. Independent of surgical experience, all patients demonstrated similar improvements in clinical outcomes. These findings appear to suggest that although surgical experience may improve perioperative parameters (operative time, length of hospitalization), an MIS LD may initially be performed safely without prior experience.

[Interventions on the intervertebral discs. Indications, techniques and evidence levels]

CLINICAL ISSUE

Over the last decades a number of different minimally invasive interventions have been proposed for the treatment of intervertebral disc herniation and degeneration. All of these interventions aim at relieving pressure from compressed nerve roots by mechanical ablation, chemical dissolution, evaporation or coagulation of disc tissue.

STANDARD TREATMENT

Microsurgical sequestrectomy with direct visualization of the spinal canal.

TREATMENT INNOVATIONS

Minimally invasive intradiscal interventions, such as chemonucleolysis, manual and automated disc decompression, laser disc decompression, nucleoplasty and thermal anular radiofrequency (RF) techniques with posterolateral access to the intervertebral disc.

PERFORMANCE

The effectiveness and safety of the different minimally invasive procedures are compared to the standard surgical procedure on the basis of a literature review.

ACHIEVEMENTS

For patients with disc herniation requiring surgery, microsurgical sequestrectomy is the treatment of choice, while discectomy is obsolete. Intradiscal procedures have a low level of evidence while long-term results are still lacking. Randomized controlled trials are required to generate evidence-based results.

PRACTICAL RECOMMENDATIONS

Indications for treatment should be established by an interdisciplinary team with the choice of treatment depending on the interventionalist's expertise and skills. In carefully selected patients scheduled for elective treatment, the different minimally invasive procedures allow adequate treatment when performed by an experienced interventionalist.

Evaluation of Transforaminal Endoscopic Discectomy in Treatment of Obese Patients with Lumbar Disc Herniation

Background

This study aimed to evaluate the efficacy of transforaminal endoscopic discectomy (TED) in the treatment of obese patients with lumbar disc herniation (LDH).

Material/Methods

A total of 69 obese patients with LDH (35 males and 34 females; age range, 24 to 43 years; median age, 34 years) were included in this study. These patients had undergone TED from March 2011 to December 2015 in the Third Hospital of Hebei Medical University. Their clinical and follow-up data were prospectively analyzed. The degree of pain and disability were measured on the basis of the Visual Analog Scale (VAS) at 1 day before surgery, immediately after surgery, and 3 months after surgery. Neurologic functions were measured on the basis of the Japanese Orthopaedic Association (JOA) system 1 day before surgery and 3 months after surgery. The MacNab score at last follow-up was recorded to evaluate the early clinical efficacy. Complications during and after the operation were recorded to evaluate the safety of surgery.

Results

Two patients experienced abnormal sensations in the export nerve root zone postoperatively, which disappeared after 3 days of treatment with dehydration and administration of hormone (dexamethasone). Three cases of recurrence were observed at 6 months, 7 months, and 9 months postoperatively; they were scheduled to receive total laminectomy combined with bone grafting internal fixation. A total of 67 patients were followed up for 3–23 months and mean follow-up was 11.8 months. The VAS scores at postoperative 3 months and 1 year were significantly reduced compared to that before the operation, with significant differences between them (t=43.072, P<0.05; t=43.139, P<0.05). The JOA scores at last follow-up postoperatively was significantly higher than that before surgery (t=−60.312, P<0.05). At the last follow-up, 17 cases (25.3%) had excellent outcomes, 39 (58.2%) good, 7 (10.4%) fair, and 4 (5.9%) poor. Overall, 83.5% of patients had excellent or good rates.

Conclusions

The early efficacy of TED is relatively good and safe for the selected obese patients with LDH in this study. Larger-sample studies with longer duration and follow-up are required to detect the safety and effectiveness of TED.

Chronic refractory myofascial pain and denervation supersensitivity as global public health disease

Chronic pain with a 30.3% global prevalence significantly impacts universal health. Low back pain has a 9.4% prevalence worldwide causing the most widespread disability. Neck pain ranks 4th highest regarding years lived with disability with a 4.9% prevalence worldwide. The principal cause of pain in 85% of patients visiting a tertiary pain clinic has a myofascial origin. The root cause is multifocal neuromuscular ischaemia at myofascial trigger points from muscle tightening and shortening following spondylotic radiculopathy induced partial denervation. Chronic refractory myofascial pain (CRMP) is a neuromusculoskeletal disease needing management innovations. Using electrical twitch-obtaining intramuscular stimulation (eToims), we provide objective evidence of denervation supersensitivity in multiple myotomes as cause, aggravation and maintenance of CRMP. This study underscores our previous findings that eToims is safe and efficacious for long-term use in CRMP. eToims aids potential prevention (pre-rehabilitation), simultaneous diagnosis, treatment (rehabilitation) and prognosis in real time for acute and CRMP management.

Lumbar Endoscopic Microdiscectomy: Where Are We Now? An Updated Literature Review Focused on Clinical Outcome, Complications, and Rate of Recurrence

Endoscopic disc surgery (EDS) for lumbar spine disc herniation is a well-known but developing field, which is increasingly spreading in the last few years. Rate of recurrence/residual, complications, and outcomes, in comparison with standard microdiscectomy (MD), is still debated and need further data. We performed an extensive review based on the last 6 years of surgical series, systematic reviews, and meta-analyses reported in international, English-written literature. Articles regarding patients treated through endoscopic transforaminal or interlaminar approaches for microdiscectomy (MD) were included in the present review. Papers focused on endoscopic surgery for other spinal diseases were not included. From July 2009 to July 2015, we identified 51 surgical series, 5 systematic reviews, and one meta-analysis reported. In lumbar EDS, rate of complications, length of hospital staying, return to daily activities, and overall patients' satisfaction seem comparable to standard MD. Rate of recurrence/residual seems higher in EDS, although data are nonhomogeneous among different series. Surgical indication and experience of the performing surgeon are crucial factors affecting the outcome. There is growing but still weak evidence that lumbar EDS is a valid and safe alternative to standard open microdiscectomy. Statistically reliable data obtained from randomized controlled trials (better if multicentric) are desirable to further confirm these results.