Efficacy of Transforaminal Endoscopic Spine System (TESSYS) Technique in Treating Lumbar Disc Herniation

The modified transforaminal endoscopic technique in treating intracanalicular combining foraminal and/or extraforaminal lumbar disc herniations

BACKGROUND

To develop a modified transforaminal endoscopic spine system (TESSYS®) technique for treating intracanalicular combining foraminal and/or extraforaminal lumbar disc herniation (ICFE-LDH), and evaluate the technical efficacy and safety.

METHODS

Twenty-three patients with ICFE-LDH underwent the modified TESSYS technique were enrolled. Magnetic resonance imaging (MRI) was used to verify the reduction of herniated disc. Pre- and post-operative neurological functions were compared by visual analogue scale (VAS) score, Oswestry disability index (ODI) and the modified MacNab criteria. The technical safety was evaluated by surgical complications.

RESULTS

MRI demonstrated reductions of disc herniations in 22 patients (95.7%) after surgeries. The VAS scores were significantly improved at 1 year follow-up (low back: P=0.001, lower limbs: P<0.001), as well as ODI scores (P<0.001). 22 patients had achieved excellent and good recovery postoperatively according to the modified MacNab criteria. One patient (4.3%) underwent a reoperation due to postoperative recurrence of disc herniation. Another patient complained postoperative causalgia in 8 weeks, the symptom alleviated after conservative treatment at 1 year follow-up (VAS: back, 3, lower limbs, 0; ODI: 20%). The incidence rate of surgical complication was 8.7%.

CONCLUSIONS

The modified TESSYS technique is a minimally-invasive, effective and safe surgery for treating ICFE-LDHs in selected patients.

A Mobile Outside-in Technique of Transforaminal Lumbar Endoscopy for Lumbar Disc Herniations

Percutaneous endoscopic transforaminal lumbar discectomy (PETLD) has now become a standard of care for the management of lumbar disc disease. There are two techniques for the introduction of a working cannula with respect to disc-outside-in and inside-out. The aim of this prospective study is to describe the technical aspects of a novel mobile outside-in method in dealing with different types of disc prolapse. A total of 184 consecutive patients with unilateral lower limb radiculopathy due to lumbar disc prolapse were operated on with the mobile outside-in technique of PETLD. Their clinical outcomes were evaluated based on the type of disc prolapse they had, a visual analog scale (VAS) leg pain score, the Oswestry Disability Index (ODI), and the Macnab criteria. The completeness of the decompression was documented with a postoperative magnetic resonance imaging. The mean age of the patients was 50 ± 16 years and the male/female ratio was 2:1. The mean follow-up was 19 ± 6 months. A total of 190 lumbar levels were operated on (L1-L2: n = 4, L2-L3: n = 17, L3-L4: n = 27, L4-5: n = 123, and L5-S1: n = 19). Divided into types, the patient distribution was central: n = 14, paracentral: n = 74, foraminal: n = 28, far lateral: n = 13, superior-migrated: n = 8, inferior migrated: n = 38, and high canal compromise: n = 9. The mean operative time was 35 ± 12 (25 - 56) min and the mean hospital stay was 1.2 ± 0.5 (1-3) days. The VAS score for leg pain improved from 7.5 ± 1 to 1.7 ± 0.9. The ODI improved from 70 ± 8.3 to 23 ± 5. According to the Macnab criteria, 75 patients (40.8%) had excellent results, 104 patients (56.5%) had good results, and 5 patients (2.7%) had fair results. Recurrence (including early and late) was seen in 15 out of the 190 levels that were operated on (7.89%). This article presents a novel outside-in approach that relies on a precise landing within the foramen in a mobile manner and does not solely depend upon the enlargement of the foramen. It is more versatile in application and useful in the management of all types of disc prolapse, even in severe canal compromise and high migration.

Which clinical and radiological variables could predict clinical outcomes of percutaneous endoscopic lumbar discectomy for treatment of patients with lumbosacral disc herniation?

BACKGROUND CONTEXT

Percutaneous endoscopic lumbar discectomy (PELD) is one of minimally invasive techniques to treat patients with low back and radiating pain resulting from lumbosacral disc herniation (LDH).

PURPOSE

The purpose of this study is to evaluate the clinical efficacy of PELD to treat patients with low back and radicular pain due to LDH and to investigate which clinical and radiological variables have the ability to predict clinical outcome after PELD.

STUDY DESIGN/SETTING

This is a retrospective study design carried out at a spine hospital.

PATIENT SAMPLE

The sample comprised 75 patients who had undergone PELD for treatment of low back and radiating leg pain resulting from LDH and who could be followed up for at least 12 months.

OUTCOMES MEASURES

Clinical outcomes were assessed using numeric rating scale for back and radiating leg pain (NRS back and leg), Oswestry Disability Index (ODI), and modified MacNab criteria at 1 month (short-term follow-up) and at least 12 months (long-term follow-up) after PELD.

METHODS

The patients were divided into successful and unsuccessful outcome groups according to improvement of NRS back, NRS leg, and ODI (%) at long-term follow-up period. We compared the various clinical and radiological variables between the two groups to identify which variables could be the prognostic factors of clinical outcomes of PELD. This analysis was performed in terms of whole population, the subgroup of dominant back pain, and the subgroup of dominant leg pain, respectively.

RESULTS

Significant improvements were observed in NRS back, NRS leg, ODI (%), and modified MacNab criteria at short-term and long-term follow-up after PELD. Positive straight leg raising (SLR) was significantly related to successful outcome as to NRS leg and ODI (%), and longer pain duration also showed significant relationship with unsuccessful outcomes as to NRS leg in whole population. Positive SLR had significant relationship with successful NRS leg as well as successful ODI (%) in the subgroup of dominant leg pain.

CONCLUSIONS

PELD was an effective treatment in patients with back and leg pain due to LDH. Positive SLR had the predictive ability to successful reduction of radiating leg pain and successful functional improvement. Longer pain duration was also related to unsuccessful reduction of radiating leg pain.

PTED study: design of a non-inferiority, randomised controlled trial to compare the effectiveness and cost-effectiveness of percutaneous transforaminal endoscopic discectomy (PTED) versus open microdiscectomy for patients with a symptomatic lumbar disc herniation

INTRODUCTION

Lumbosacral radicular syndrome is often caused by a disc herniation. The standard surgical technique to remove a disc herniation is open microdiscectomy. An alternative technique is percutaneous transforaminal endoscopic discectomy (PTED), which is less invasive. In the Netherlands, PTED is not currently considered as standard care, and therefore not reimbursed within public health insurance. A pragmatic, multicentre, non-inferiority, randomised controlled trial has been designed to determine the effectiveness and cost-effectiveness of PTED versus open microdiscectomy for the treatment of lumbar disc herniation.

METHOD AND ANALYSIS

In total, 682 patients between 18 and 70 years of age with >10 weeks of radiating pain or with >6 weeks of excessive radiating pain are to be recruited from participating centres. Patients must have an indication for surgery based on an MRI demonstrating compression of the nerve root from a lumbar disc herniation. Patients are to be randomised to PTED or open microdiscectomy. The primary outcome is self-reported leg pain measured by the 0-100 mm Visual Analogue Scale. Secondary outcomes include self-reported health and functional status, back pain, self-perceived recovery and a physical examination. Outcomes will be measured the day following surgery, at 2, 4 and 6 weeks, and at 3, 6, 9, 12 and 24 months. Physical examination will be performed at 6 weeks, and 3 and 12 months. An economic evaluation will be performed from a societal perspective and cost questionnaires will be used (eg, EQ-5D-5L). The data will be analysed longitudinally; the non-inferiority margin for the primary outcome is 5. Bootstrapping techniques will be used for the economic evaluation.

ETHICS AND DISSEMINATION

This study has received approval of the Medical Ethical Committee of the VU Medical Centre Amsterdam: NL50951.029.14. The results will be published in an international peer-reviewed scientific journal.

TRIAL REGISTRATION NUMBER

NCT02602093; Pre-results, recruiting stage.

Comparison of the effects of local anesthesia and epidural anesthesia for percutaneous transforaminal endoscopic discectomy in elderly patients over 65 years old

BACKGROUND

Local anesthesia (LA) is recommended for percutaneous transforaminal endoscopic discectomy (PTED) but clinical practice indicates that LA cannot achieve satisfactory pain management during PTED.

OBJECTIVES

The study aimed to investigate the comparisons between LA and EA for PTED in elderly population over 65 years old.

METHODS

We performed a retrospective analysis of patients over 65 years old received PTED from May 2013 to December 2014. And patients were divided into two groups according to the anesthesia method. The data collected for analysis including operative time, fluoroscopy time, postoperative bed time, visual analog scale (VAS), Oswestry Back Pain Disability Index (ODI), the global outcome based on the Macnab outcome criteria, satisfaction rate of anesthesia, and complications.

RESULTS

A total of 132 consecutive patients were enrolled in this study. There were 65 patients in LA group and 67 patients in EA group. Compared to LA group, EA group had longer operative time (P < 0.001) and postoperative bed time (P < 0.001) but shorter fluoroscopy time, (P < 0.001), smaller VAS score of lumbar pain intraoperatively (P < 0.001), 1-h postoperatively (P < 0.001) and 1-week postoperatively (P < 0.001). Similarly, EA group had lower VAS score of leg pain intraoperatively (P < 0.001) and 1-h postoperatively (P < 0.001). In additions, higher satisfaction rate of anesthesia was observed in EA group (P = 0.029).

CONCLUSIONS

EA and LA for PTED achieved comparable clinical outcomes in elderly population over 65 years old. However, compared to LA for PTED, EA had a better performance in pain management.

Comprehensive comparison of therapeutic efficacy of radiofrequency target disc decompression and nucleoplasty for lumbar disc herniation: a five year follow-up

PURPOSE

To compare the therapeutic efficacy of radiofrequency target disc decompression(TDD) and nucleoplasty for lumbar disc herniation.

METHODS

Two hundred sixty patients with lumbar disc herniation were divided into two groups: target disc decompression group (group T, n = 147) and nucleoplasty group (group N, n = 113). Visual analogue scale (VAS) and functional rating index (FRI) were measured at one, three, six, 12, 24, and 60 months after the surgery. Hospitalization time, operation time, complications, and recurrence/invalid were compared between the two groups.

RESULTS

Compared with the pre-operation, the VAS and FRI in both groups were significantly decreased in post-operation(P < 0.01). The VAS and FRI in group T have no significant difference compared to those in group N. The hospitalization and operation time of group T were significantly longer than those in group N. There was no significant difference of the occurrence of complications and disease recurrence/invalid during the follow-up between the two groups. Logstic regression analysis showed that operation time was an independent factor in the prognosis. Operation time affects the treatment effect. Shorter operation time leads to better therapeutic efficacy, and longer operation time leads to poor therapeutic efficacy.

CONCLUSIONS

Both TDD and nucleoplasty can reduce pain in patients with lumbar disc herniation and improve quality of life. Group N had shorter hospitalization and operation time than group T.

Effects of release and decompression techniques on nerve roots through percutaneous transforaminal endoscopic discectomy on patients with central lumbar disc herniation

The clinical effects and safety of release and decompression techniques on nerve roots through percutaneous transforaminal endoscopic discectomy (PTED) while treating patients with central lumbar disc herniation (CLDH) were explored. Patient cases of lumbar and leg pain treated in Bethune International Peace Hospital from July 2013 to October 2015 were collected retrospectively. The patients in these cases received imaging examinations such as computed tomography and magnetic resonance imaging. Among these cases, 37 CLDH patients with no other complications were selected for this study. A total of 22 males and 15 females aged 28–54 years, with an average age of 36.8±1.5 years, were the subjects of the study. Their disease course was from 1 month to 3 years, with a median course time of 1.5 years. Visual analogue scale (VAS), Japanese Orthopaedic Association (JOA) scoring and the MacNab method were used to evaluate treatment effects. After permission from patients or their family members, release and decompression techniques of nerve roots were performed through PTED. All patients had successful surgery. Their average surgery time was 41.3 (25.5–57.1) min. A physician followed-up each patient from 0 to 18 months after surgery, with the average follow-up period of 12.1 months. VAS scoring of lower limbs was 7.95±0.82 before surgery and 2.28±0.35, 3 months after surgery. VAS scoring of lower limbs was 2.06±0.58, 1 year after surgery and 2.12±0.23 at the last follow-up appointment. JOA scoring was 12.6±0.72 before surgery and 20.4±1.08, 3 months after surgery. JOA scoring was 21.1±0.82 1 year after surgery and 21.2±0.36 at the last follow-up. Differences are of statistical significance (P<0.05). There were no complications for any of the cases. One patient did not improve after surgery, so a laminectomy and bone grafting internal fixation were performed. Two patients relapsed after surgery and received laminectomy and bone grafting internal fixation. The total percentage of excellent and good rates was 83.5%. In conclusion, release and decompression techniques on nerve roots using PTED while treating CLDH resulted in a safe, effective and less traumatic outcome with fewer complications and quicker pain relief than alternative treatments. Due to the results of this study, the use of these techniques in treating CLDH should be more widely considered.

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.