Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study

Full-Endoscopic Visualized Foraminoplasty and Discectomy Under General Anesthesia in the Treatment of L4-L5 and L5-S1 Disc Herniation

STUDY DESIGN

Retrospective analysis of clinical records.

OBJECTIVE

The aim of this study is to evaluate the clinical outcomes and neurological complications of full-endoscopic visualized foraminoplasty and discectomy under general anesthesia for the treatment of L4-L5 and L5-S1 disc herniation.

SUMMARY OF BACKGROUND DATA

Full-endoscopic visualized foraminoplasty and discectomy, which is our newly developed technique, has been used in the treatment of lumbar disc herniation and lumbar spinal stenosis. While the clinical effect, safety, and neurological complications of full-endoscopic visualized foraminoplasty and discectomy under general anesthesia are still uncertain.

METHODS

Between May 2015 and April 2017, 84 patients with lumbar disc herniation were included, and categorized into L4-L5 group and L5-S1 group according to the discectomy segment. Full-endoscopic visualized foraminoplasty and discectomy was performed under general anesthesia. Operative time, fluoroscopy time, hospitalization time, and complications were recorded. Each patient included was followed for at least 12 months. Visual analog scale score for leg and back pain and Oswestry Disability Index score were evaluated preoperatively and at 3, 6, and 12 months postoperatively. The modified MacNab criteria were also used to evaluate surgical effectiveness.

RESULTS

The mean operative time, fluoroscopy time, and hospitalization time at L4-L5 and L5-S1 were of no significant difference. The mean visual analog scale and Oswestry Disability Index postoperative scores were significantly improved over the preoperative scores. Intraoperative nerve injury occurred in one case at L4-L5, with a neurological complication rate of 2.1% in L4-L5 group. One case at L4-L5 suffered recurrence 2 weeks after the surgery, resulting in a recurrence rate of 2.1% in L4-L5 group. This recurrence case was treated by a second full-endoscopic visualized foraminoplasty and discectomy under general anesthesia.

CONCLUSION

Full-endoscopic visualized foraminoplasty and discectomy under general anesthesia is efficient and safe for the treatment of L4-L5 and L5-S1 disc herniation.

LEVEL OF EVIDENCE

4.

Trends in Incidence and Treatment of Herniated Lumbar Disc in Republic of Korea : A Nationwide Database Study

OBJECTIVE

This study aimed to determine the incidence and analyze trends of the herniated lumbar disc (HLD) based on a national database in the Republic of Korea (ROK) from January 2008 to December 2016.

METHODS

This study was a retrospective analysis of data obtained from the national health-claim database provided by the National Health Insurance Service for 2008-2016 using the International Classification of Diseases. The crude incidence and age-standardized incidence of HLD were calculated, and additional analysis was conducted according to age and sex. Changes in trends in treatment methods and some treatments were analyzed using the Korean Classification of Diseases procedure codes.

RESULTS

The number of patients diagnosed with HLD was 472245 in 2008 and increased to 537577 in 2012; however, it decreased to 478697 in 2016. The pattern of crude incidence and the standardized incidence were also similar. Overall, the incidence of HLD increased annually for the 30s, 40s, 50s, and 70s until 2012 and then decreased. However, the incidence of HLD for the 80s continued to increase. The crude incidence of HLD in female patients exceeded that of male patients in their middle age (30s or 40s) and was 1.5-1.6 times higher than in male patients in their 60s. The total number of open discectomy (OD) increased from 71598 in 2008 to 93942 in 2012 and then decreased to 85846 in 2016. The rate of younger patients (the 20s, 30s, and 40s) who underwent OD was decreased, and the rate of younger patients who underwent percutaneous endoscopic lumbar discectomy was increased. However, the rate of older patients (the 70s and 80s) who underwent OD was continuously increased.

CONCLUSION

This nationwide data on HLD from 2008 to 2016 in the ROK demonstrated that the crude incidence and the standardized incidence increased until 2012 and then decreased. The annual crude incidence was different according to age and sex. These findings may be considered when deciding future health policy, especially in countries with a similar national health insurance system (or with plans to adopt).

Revision Surgery after Percutaneous Endoscopic Transforaminal Discectomy Compared with Primary Open Surgery for Symptomatic Lumbar Degenerative Disease

Objective

To evaluate the clinical outcome of reoperation after percutaneous endoscopic lumbar discectomy (PELD) as compared with primary spinal decompression and fusion.

Methods

A retrospective study from December 2014 to December 2017 was conducted at Peking Union Medical College Hospital and comprised 39 patients with symptomatic lumbar degenerative disease (LDD): 13 post‐PELD who underwent reoperation (revision surgery group) and 26 who received primary spinal decompression and fusion (primary open surgery group). The two groups were compared regarding: operative time, blood loss, transfusion, hospitalization, postoperative visual analog scale (VAS) scores, Oswestry Disability Index (ODI) scores, Japanese Orthopedic Association (JOA) improvement rate, and postoperative complications. The Mann–Whitney U‐test was applied to analyze continuous parameters, and the χ²‐test for categorical parameters. Fisher's exact test was used for small data subsets.

Results

There was no statistically significant difference between the two groups in mean age (52.7 years vs 52.9 years), gender ratio (6 men‐to‐7 women vs 12 men‐to‐14 women), body mass index, medical history, preoperative diagnosis, or surgical spine level (P > 0.05). The mean operative time of the revision surgery group was significantly longer than that of the primary open surgery group (160.0 min vs 130.2 min, P < 0.05). The revision surgery group also had a significantly higher mean estimated blood loss, postoperative drainage, and length of hospital stay (P < 0.05). However, no significant differences were found between the two groups in terms of hemoglobin and hematocrit values, preoperatively and postoperatively. The rate of transitional neurological irritation was higher in the revision surgery group (61.5% vs 3.8%; P < 0.05), as was intraoperative durotomy and cerebrospinal fluid leakage (30.8% vs 3.8%, P < 0.05). At 1 month, the VAS and ODI scores of the primary open surgery group were significantly better than those of the revision surgery group, while the improvement in JOA scores was similar. After 6 and 12 months’ follow‐up, the VAS and ODI scores and the rates of JOA improvement were comparable.

Conclusion

Patients with LDD who received primary spinal decompression and fusion experienced lower rates of perioperative complications and shorter hospitalization compared with patients who underwent revision surgery after PELD, but the clinical outcomes at the last follow‐up of both groups were satisfactory.

Radiographic and clinical outcomes of huge lumbar disc herniations treated by transforaminal endoscopic discectomy

OBJECTIVES

Large Central disc herniations (occupying more than 50% of canal area) are notorious as they are generally associated with worse outcomes and are technically difficult to manage. Transforaminal endoscopy (TELD) has evolved to become an interesting alternative for lumbar disc herniations. The aim of the paper is to review our technique of transforaminal endoscopy in large central disc herniations and describe the clinical and radiographic results. We also describe an innovative technique of intraoperative epidurography to assess the adequacy of decompression in some cases with severe canal compromise.

PATIENTS AND METHODS

We performed a retrospective analysis of all the patients undergoing TELD from December 2012 to October 2018 for huge central lumbar disc herniations. The procedure was done under local anaesthesia and required a more horizontal approach angle, undercutting of superior articular process and posterior annular release to reach the herniated fragment in the epidural space. In severe cases, a radiopaque dye was introduced via trans-sacral catheter to check the adequacy of decompression. The disc height, lumbar lordosis, segmental lordotic angle on standing radiographs and Canal cross sectional area(CSA) on MRI were evaluated preoperatively and compared with postoperative images at the end of 1 year/final follow-up. The Visual analogue scale(VAS) for Back and Leg pain and Oswestry disability index (ODI), MacNab criteria, return to daily activities, return to work, patient satisfaction rate and recommendation to others were the clinical outcomes evaluated. The percentage of patients achieving the Minimal clinically important difference (MCID) of 3 points for VAS and 12 points for ODI was calculated.

RESULTS

A total of 18 patients, with an average age of 35.1years (range 20-61), were operated. The mean VAS back improved from 5.7(±1.77) to 1(±0.77) and VAS leg improved from 7.3(±1.37) to 1.1(±1.09). The ODI improved from 49.88(±11.42) to 13.88(±7.28) at final follow-up. According to MacNab criteria, 17 patients had excellent and 1 had good outcome at final follow-up. The patient satisfaction rate was 90.5%, with 94% patient recommendation rate. All the patients returned to daily activities and work/modified work within a median of 5 weeks. There was 1 patient who required conversion to open surgery due to incidental dural tear, 1 patient who had a remnant disc required a revision tubular discectomy and 1 patient who had recurrence at 6 weeks and again at 2 years which was treated by repeat TELD. Five patients had impending cauda equina. All the patients achieved the MCID for VAS and ODI within a median period of 6 weeks and 3 months, respectively. The recovery rate was 90.1%. Five patients had grade 4 weakness of great toe/ankle dorsiflexion, one also had ankle flexion weakness preoperatively which improved after surgery. The CSA improved from a preoperative mean of 62.26(±30.3)mm² to 122.16(±56.5)mm² postoperatively. The CSA improved to 141.05(±63.86)mm² at 1 year followup. The average disc height which was 9.71 mm(±2.4) was maintained at follow-up of one year which was 9.21 mm(±2.4). The lumbar lordosis and segmental lordotic angle changed from 27.08°(±15.9) and 2.82°(±5.7) to 35.8°(±8.56) and 4.85°(±4.39) respectively.

CONCLUSION

TELD may be considered as an alternative to microdiscectomy or fusion procedures for huge central disc herniations with favourable outcomes. However, sufficient expertise with the procedure is necessary. Intraoperative decompression may be confirmed with intraoperative epidurography. The patient acceptability of the procedure is good and causes minimal disruption of the normal anatomy.

[Percutaneous Lumbar Endoscopic Discectomy: Presentation of 60 Cases Intervened in Argentina with Awake Patients]

INTRODUCTION

Percutaneous endoscopic lumbar discectomy (PELD) is a minimally invasive technique that has been used in different countries since the late eighties for the treatment of herniated discs.

OBJECTIVE

The objective of this study was to describe the results of PELD in a series of awake patients, treated with epidural anesthesia and mild sedation.

MATERIALS AND METHODS

In a group of 60 patients, who together had 77 discs operated on between April 2016 and March 2018, data were collected on patient age and gender, clinical presentation, and MRI abnormalities. The main outcome of interest was the difference between preoperative and postoperative Oswestry (Oswestry disability index [ODI]) scores 8 weeks after the procedure. Macnab criteria, operation duration, length of hospitalization, surgical complications, and the need for reoperation were other outcomes evaluated. All patients received epidural anesthesia and mild sedation.

RESULTS

The average reduction in ODI at 8 weeks was 48 points (standard deviation [SD] = 5), representing an average percentage reduction of 85% (SD = 8). By Macnab's criteria, 85% of patients experienced either an excellent or good result, while 10% and 5% had a fair and poor result, respectively. Average surgery time was 50 min and in-hospitalization stay 8.6 h.

CONCLUSIONS

In our series of surgical patients with lumbar disc herniations, PELD yielded very good results, manifest as significantly reduced pain, brief procedural durations, no complications, and short hospital stays. Patients accepted the option of being awake and immediately ambulatory, and the approach proved highly feasible to execute.

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.

Short- and long-term results of percutaneous full-endoscopic and microsurgical lumbar discectomy: prospective cohort study

Objective. To analyze immediate and long-term results of percutaneous endoscopic and microsurgical discectomy.

Material and Methods. A prospective cohort study in two groups of patients was conducted in 2015–2018. The observation period was 6–42 months. Group 1 included 110 patients who underwent percutaneous endoscopic lumbar discectomy, and Group 2 – 331 patients who underwent microdiscectomy. Efficiency was assessed using NRS-11, ODI, SF-36, and MacNab questionnaires.

Results. The operating time, bed day number, and disability period were shorter in Group 1 (p < 0.001). The average effective dose of radiation exposure to the patient was 4.4 mSv in transforaminal endoscopy, and 0.8 mSv in interlaminar and microsurgical discectomy. There were no significant intergroup differences in frequency and types of complications and reoperations. The portion of symptomatic hernia recurrence in Group 1 was 10 %, in Group 2 – 4.8 %. Significant differences in neurological outcomes and quality of life were not revealed. Good and excellent outcomes according to MacNab criteria were noted in 78.2 % and 84.9 %, in Groups 1 and 2, respectively.

Conclusion. The percutaneous endoscopic discectomy allows reducing hospital stay length and disability period, while having clinical efficacy equal to that of other disectomy methods. A statistically insignificant increase in the risk of hernia recurrence after percutaneous endoscopic discectomy was noted.

Cost-effectiveness of microdiscectomy versus endoscopic discectomy for lumbar disc herniation

BACKGROUND CONTEXT

Microdiscectomy is a standard technique for the surgical treatment of lumbar disc herniation (LDH). Endoscopic discectomy (ED) is another surgical option that has become popular owing to reports of shorter hospitalization and earlier return to work. No study has evaluated health care costs associated with lumbar discectomy techniques and compared cost-effectiveness.

PURPOSE

To assess the cost-effectiveness of four surgical techniques for LDH: microdiscectomy (MD), transforaminal endoscopic lumbar discectomy (TELD), interlaminar endoscopic lumbar discectomy (IELD), and unilateral biportal endoscopic discectomy (UBED).

STUDY DESIGN AND SETTING

Retrospective analysis.

PATIENT SAMPLE

Patients who underwent either MD or ED for primary LDH with 1-year follow-up between the ages of 20 and 60 years old.

OUTCOME MEASURES

Incremental cost-effectiveness ratio (ICER).

METHODS

Five hundred sixty-five patients aged 20-60 years who underwent treatment using one of the four surgical techniques with at least 1-year follow-up were reviewed. Health care costs were defined as the sum of direct and indirect costs. The former included the covered and uncovered costs of the National Health Insurance from operation to 1-year follow-up; indirect costs included costs incurred by work loss. Direct and indirect costs were evaluated separately. ICER was determined using cost/quality-adjusted life year (QALY). Health care costs and ICER were compared statistically among the four surgical groups. Cost-effectiveness was compared statistically between MD and ED.

RESULTS

One hundred fifty-seven patients who underwent TELD, 132 for IELD, 140 for UBED, and 136 for MD were enrolled. The direct costs of TELD, IELD, UBED, and MD were $3,452.2±1,211.5, $3,907.3±895.3, $4,049.2±1,134.6, and $4,302.1±1,028.9, respectively (p<.01). The indirect costs of TELD, IELD, UBED, and MD were $574.5±495.9, $587.8±488.3, $647.4±455.6, and $759.7±491.7, respectively (p<.01). The 1-year QALY gains were 0.208 for TELD, 0.211 for IELD, 0.194 for UBED, and 0.186 for MD. ICER (costs/QALY) was the highest for MD ($34,840.4±25,477.9, p<.01). Compared with MD, ED saved an additional net of $8,064 per QALY (p<.01). There was no significant difference in the ICERs among the three endoscopic techniques.

CONCLUSIONS

ED was more cost-effective compared with MD at 1-year follow up.

Transforaminal full-endoscopic lumbar discectomy under local anesthesia in awake and aware conditions: the inside-out and outside-in techniques

PURPOSE OF THE REVIEW

Transforaminal full-endoscopic lumbar discectomy (TELD) under local anesthesia was first introduced in Japan in 2003. Initially referred to as percutaneous endoscopic discectomy, in 2018, a consensus was reached worldwide and the preferred term is now TELD. The procedure requires only an 8-mm skin incision and causes minimal damage to the paravertebral muscles. Thus, it is the least invasive disc surgery. In this review, we introduce two types of the TELD surgery.

RECENT FINDINGS

Initially, TELD was performed as the "inside-out" technique but was associated with reports of postoperative dysesthesia due to exiting nerve injury. Recently, the "outside-in" technique after foraminoplasty was proposed for safer insertion of the cannula into the disc. Foraminoplasty can widen the narrow foramen, thereby allowing the 8-mm cannula to pass through easily and safely, and thus injury to the exiting nerve root can be theoretically avoided. We described two types of the TELD in this review. Surgeons should be familiar with the inside-out and outside-in techniques for TELD; therefore, we can select appropriate technique for each case.

Mixed Reality-Based Preoperative Planning for Training of Percutaneous Transforaminal Endoscopic Discectomy: A Feasibility Study

OBJECTIVE

To explore the effect of preoperative planning using mixed reality (MR) on training of percutaneous transforaminal endoscopic discectomy (PTED).

METHODS

Before the training, we invited an experienced chief physician to plan the puncture path of PTED on the X-ray films of the lumbar spine model and the 3D Slicer platform, respectively, and used this as the standard to guide trainees. In the aggregate, 60 young residents were randomly divided into Group A (N = 30) and Group B (N = 30). Group A learned the 2-dimensional standard planning route, whereas Group B learned the standard route planning based on MR through the 3D Slicer platform. Then, trainees were asked to conduct PTED puncture on a lumbar spine model. Questionnaires were distributed to trainees before and after the training. During the training, puncture times, operating time (minutes), and fluoroscopy times were recorded.

RESULTS

After the training, it was obvious that more trainees showed their recognition of MR, believing that MR could help preoperative planning and training of PTED. Their high satisfaction with the training indicated the success of our training. Moreover, puncture times, operating time (minutes), and fluoroscopy times of Group B were significantly lower than those of Group A.

CONCLUSIONS

MR technology contributes to preoperative planning of PTED and is beneficial in the training of PTED. It significantly reduces puncture times and fluoroscopy times, providing a standardized method for the training of PTED.

EVALUATION OF LUMBAR ENDOSCOPIC DISCECTOMY IN OBESE PATIENTS

ABSTRACT Objectives: Obesity is a public health problem with high morbidity and mortality rates and perioperative complications in the general population. Minimally invasive procedures are promising alternatives to perioperative complications in individuals with a high body mass index (BMI). Endoscopic lumbar discectomy has been gaining popularity in this regard. However, there are few descriptions in the literature about the endoscopic approach to improve pain and quality of life in obese individuals. Likewise, it is not determined whether individuals with a high BMI have more complications in this type of surgical approach. Methods: A longitudinal retrospective case-control study was performed with 63 subjects submitted to endoscopic discectomy, divided into 2 groups according to BMI (Group A, BMI ≥ 30kg/m2 and Group B, BMI <30kg/m2), in order to compare improvement in quality of life through the Oswestry Disability Index (ODI) and pain improvement by the Visual Analogue Scale (VAS), as well as to observe the incidence of postoperative complications in both groups. Results: There was no difference in postoperative ODI (p=0.36) and VAS (p=0.54) between groups, nor was there a statistical difference in the incidence of complications between groups (p=0.56). Conclusions: Endoscopic discectomy brings similar results in pain and quality of life in obese and non-obese patients without causing higher rates of complications. Level of Evidence III; Case-Control Study.

The benefit zone of full-endoscopic spine surgery

Minimally invasive spine procedures have undergone rapid development during the last decade. Efforts to decrease muscle crush injuries during prolonged retraction, avoid significant soft tissue stripping and minimize bony resection are surgical principles that are employed to prevent iatrogenic instability and provide patients with decreased post-operative pain and disability. Full-endoscopic spine surgery represents a tool for the spine surgeon to provide targeted access to spinal pathology utilizing these principles. Endoscopic techniques have seen over 30 years of evolution and innovation, however, early iterations of these techniques largely focused on transforaminal lumbar microdiscectomies. Currently, endoscopic techniques are utilized for approaching pathology in the cervical, thoracic and lumbar spine. There has been a growing body of literature that not only confirms the efficacy of these procedures but also underscores the advantages these procedures offer with respect to less morbidity and safer complication profiles. Endoscopic decompressions have been utilized in the settings of degenerative spinal stenosis, spondylolisthesis, scoliosis, previous fusion, tumor and infection. Furthermore, endoscopic interbody fusion has also been utilized in the lumbar spine as technology continues to advance. As technological innovation continues to facilitate reproducible surgical technique and expand the indications for use, we believe that endoscopic spine surgical techniques will provide surgeons with a more powerful and less morbid approach to spinal pathology that ultimately elevates the standard of care when treating our patients. We present a brief review of the history of endoscopic spine surgery, an overview of current techniques and review current outcomes of endoscopic spine surgical procedures in the context of an invasiveness/complexity index to elucidate the benefit zone of these newer techniques.

Evaluation of Dimensions of Kambin's Triangle to Calculate Maximum Permissible Cannula Diameter for Percutaneous Endoscopic Lumbar Discectomy : A 3-Dimensional Magnetic Resonance Imaging Based Study

Objective

To evaluate 3-dimensional magnetic resonance imaging (MRI) of Kambin’s safe zone to calculate maximum cannula diameter permissible for safe percutaneous endoscopic lumbar discectomy.

Methods

Fifty 3D MRIs of 19 males and 31 females (mean, 47 years) were analysed. Oblique, axial and sagittal views were used for image analysis. Three authors calculated the inscribed circle (cannula diameter) individually, within the neural (original) and bony Kambin’s triangle in oblique views, disc heights on sagittal views and root to facet distances at upper and lower end plate levels on axial views and their averages were taken.

Results

The mean root to facet distances at upper end plate level measured on axial sections increased from 3.42±3.01 mm at L12 level to 4.57±2.49 mm at L5S1 level. The mean root to facet distances at lower end plate level measured on axial sections also increased from 6.07±1.13 mm at L12 level to 12.9±2.83 mm at L5S1 level. Mean maximum cannula diameter permissible through the neural Kambin’s triangle increased from 5.67±1.38 mm at L12 level to 9.7±3.82 mm at L5S1 level. The mean maximum cannula diameter permissible through the bony Kambin’s triangle also increased from 4.03±1.08 mm at L12 level to 6.11±1 mm at L5S1 level. Only 2% of the 427 bony Kambin’s triangles could accommodate a cannula diameter of 8mm. The base of the bony Kambin’s triangle taken in oblique view (3D MRI) was significantly higher than the root to facet distance at lower end plate level taken in axial view.

Conclusion

The largest mean diameter of endoscopic cannula passable through “bony” Kambin’s triangle was distinctively smaller than the largest mean diameter of endoscopic cannula passable through “neural” Kambin’s triangle at all levels. Although proximity of exiting root to the facet joint is always taken into consideration before PELD procedure, our 3D MRI based anatomical study is the first to provide actual maximum cannula dimensions permissible in this region.

Endoscopic transforaminal lumbar interbody fusion: a comprehensive review

INTRODUCTION

Endoscopic spine surgery has been developed as a minimally invasive technique for decompression in patients with lumbar disc herniation or lumbar stenosis. Recent reports have described the use of endoscopic technology in lumbar fusion surgeries, especially for transforaminal lumbar interbody fusion (TLIF). This review aimed to summarize the current techniques of endoscopic TLIF and to discuss the benefits, limitations, and future perspectives of endoscopic lumbar fusion surgery.

AREAS COVERED

This review covered the English-language medical literature published in Medline and focused specifically on endoscopic technologies incorporated into minimally invasive TLIF. The endoscopic TLIF techniques are categorized here according to the properties of the endoscope: percutaneous endoscopic TLIF, biportal endoscopic TLIF, and microendoscopic TLIF. Even though most authors have reported favorable clinical and radiological outcomes of endoscopic TLIF, such evidence originates mainly from case series.

EXPERT OPINION

Although the current level of evidence is low and the technical relevance of the technique is controversial, the key concept and early results of endoscopic TLIF are promising. Technical advancements to improve safety and reduce technical complexity, as well as comparative cohort studies and randomized clinical trials with long-term follow-up are required to promote the adoption of endoscopic TLIF in clinical practice.

Pseudoaneurysm of a segmental lumbar artery following a full-endoscopic transforaminal lumbar discectomy: a rare approach-related complication

Full-endoscopic transforaminal lumbar discectomy is based on a puncture technique using a guide needle to reach the target area of the foramen via a percutaneous posterolateral/lateral approach. It may correlate with specific approach-related complications, as exiting nerve root injury. We report the first case of pseudoaneurysm of the lumbar segmental artery secondary to a transforaminal full-endoscopic surgery in the treatment of a lumbar herniated disc. A 39-year-old man underwent left L4-L5 full-endoscopic transforaminal lumbar discectomy for a herniated disc. Three hours after surgery, he experienced acute progressive abdominal pain. An abdomen CT scan showed contrast extravasation in the left paraspinal compartment at L4 vertebral body level. The selective left lumbar angiogram revealed a pseudoaneurysm of a side branch of the left lumbar segmental artery, which was treated by endovascular coiling. The patient made a rapid postoperative recovery without further complications and was discharged 4 days later. This report identifies a rare complication of transforaminal full-endoscopic surgery in the treatment of a herniated lumbar disc. To our knowledge this is the first case of pseudoaneurysm formation of the lumbar artery following a full-endoscopic transforaminal lumbar discectomy.

Comparison of Endoscope-Assisted and Microscope-Assisted Tubular Surgery for Lumbar Laminectomies and Discectomies: Minimum 2-Year Follow-Up Results

Purpose

This study aimed to evaluate the clinical outcomes of endoscope-assisted and microscope-assisted tubular surgery for lumbar laminectomies and discectomies.

Methods

Three hundred and seven patients with lumbar spinal stenosis (LSS) or lumbar disc herniation (LDH) at L3-4, L4-5, and L5-S1 were included in this study. The patients were treated with endoscope-assisted or microscope-assisted tubular surgery. Data on patient demographic characteristics and operative results, including ages, blood loss, operative times, hospital stay, and surgical complications were collected. Clinical outcomes were assessed based on pre- and postoperative Visual Analog Scale (VAS) scores for low-back pain (LBP) and leg pain, Oswestry Disability Index (ODI), and Japanese Orthopaedic Association (JOA) scale.

Results

Both tubular-based endoscope-assisted and microscope-assisted surgery were effective in relieving acute radicular symptoms. The results showed characteristic differences in operating times between endoscope-assisted and microscope-assisted procedures and between discectomies and laminectomies. At the last follow-up, VAS scores of LBP and leg pain, JOA scores, and ODI scores were significantly better than preoperative correlates in all groups. There were no differences between endoscope-assisted and microscope-assisted discectomies for LDH in JOA scores, ODI scores, and VAS scores, while the microscope-assisted laminectomies related to better JOA recovery rate for LSS.

Conclusions

Endoscope-assisted and microscope-assisted tubular discectomies resulted in similar clinical outcomes for LDH, while the microscope-assisted surgery may relate to better recovery rate for LSS, less surgical time, and less intraoperative dural tear.

Percutaneous endoscopic lumbar discectomy for LDH via a transforaminal approach versus an interlaminar approach: a meta-analysis

PURPOSE

The aim of this study was to systematically compare the safety and effectiveness of percutaneous endoscopic transforaminal discectomy (PETD) versus percutaneous endoscopic interlaminar discectomy (PEID) for the treatment of lumbar disc herniation (LDH).

MATERIAL AND METHODS

All studies that were performed to compare PETD with PEID to treat LDH and published until 31 August 2017 were acquired through a comprehensive search in various databases. A meta-analysis was performed using the Cochrane Collaboration's RevMan 5.3 software.

RESULTS

A total of 13 trials with 974 cases consisting of 3 randomized controlled trials, 3 prospective studies and 7 retrospective studies were included. The results suggest that patients treated with PEID experienced more significant advantages with shorter operation time, less intraoperative blood loss and less intraoperative fluoroscopy times but more complications than those treated with PETD; however, the two operative approaches did not significantly differ in terms of LDH recurrence, hospital stay, Oswestry disability index (ODI) scores, visual analogue scale (VAS) scores, Japanese Orthopaedic Association (JOA) scores and MacNab criteria at the final follow-up.

CONCLUSION

Based on the results of this study, although PEID may be superior to PETD in certain ways, some of its advantages have yet to be verified and the two interventions were not significantly different in terms of relief of symptoms and functional recovery. Therefore, PEID would be recommended for treating LDH especially at L5/S1 under certain conditions but a prudent attitude is necessary to choose between the two operative approaches before a large sample and high quality randomized controlled trials have been performed.

A Cost-utility Analysis of Percutaneous Endoscopic Lumbar Discectomy for L5-S1 Lumbar Disc Herniation: Transforaminal versus Interlaminar

STUDY DESIGN

A cost-utility analysis (CUA).

OBJECTIVE

The aim of this study was to evaluate the cost-effectiveness of percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID) techniques for the treatment of L5-S1 lumbar disc herniation (LDH).

SUMMARY OF BACKGROUND DATA

The annual cost of treatment for lumbar disc herniation is staggering. As the two major approaches of percutaneous endoscopic lumbar discectomy (PELD): percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID) have gained recognition for the treatment of L5-S1 lumbar disc herniation (LDH) and showed similar clinical outcome. ost-utility analysis (CUA) can help clinicians make appropriate decisions about optimal health care for L5-S1 LDH.

METHODS

Fifty and 25 patients were included in the PETD and PEID groups of the study. Patients' basic characteristics, health care costs, and clinical outcome of PETD and PEID group were collected and analyzed. Quality-adjusted life-years (QALYs) were calculated and validated by EuroQol five-dimensional (EQ-5D) questionnaire. Cost-effectiveness was determined by the incremental cost per QALY gained.

RESULTS

The mean total cost of the PETD group was $5275.58 ± 292.98 and the PEID group was $5494.45 ± 749.24. No significant differences were observed in hospitalization expenses, laboratory and radiographic evaluations expenses, surgical expenses, and drug costs. Surgical equipment and materials costs, and anesthesia expense in the PEID group were significantly higher than in the PETD group (P < 0.001). Clinical outcomes, including Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) scores, and Japanese Orthopaedic Association (JOA), also showed no significant differences between the two groups. The cost-effectiveness ratio of PETD and PEID were $6816.05 ± 717.90/QALY and $7073.30 ± 1081.44/QALY, respectively. The incremental cost-effectiveness ratios (ICERs) of PEID over PETD was $21887.00/QALY.

CONCLUSION

Observed costs per QALY gained for L5-S1 LDH with PETD or PEID were similar for patients, demonstrating that the two different approaches of PELD are equally cost-effective and valuable interventions.

LEVEL OF EVIDENCE

5.

Does Preservation of Ligamentum Flavum in Percutaneous Endoscopic Lumbar Interlaminar Discectomy Improve Clinical Outcomes?

Objective

Ligamentum flavum (LF) is an important anatomical structure for prevention of postoperative adhesions, but the opening of LF is necessary for percutaneous endoscopic lumbar interlaminar discectomy (PEID). Although the defect in LF is small with conventional PEID, the defect could be minimized with LF splitting technique. The objective of this study was to compare clinical outcomes of PEID with opening of LF versus splitting of LF.

Methods

A retrospective study was performed for patients underwent PEID for L5–S1. PEID with the opening of LF (open-group) was performed for 55 patients and with splitting of LF (split-group) was performed for 34 patients. The defect of LF in Open-group was 3–5 mm, but the defect was negligible in split-group because the split LF was reapproximated by its elasticity. Clinical outcomes were evaluated with Korean version of the Oswestry Disability Index (K-ODI) and visual analogue pain scores for back (VASB) and leg (VASL). The changes of clinical outcomes during postoperative 24 months between groups were evaluated with linear mixed-effects model.

Results

The clinical outcomes were similar between groups for K-ODI (p=0.98), VASB (p=0.52), and VASL (p=0.59). Each outcome demonstrated significant improvement from preoperative baseline throughout the postoperative 24 months (p<0.05). Complications included recurrence in 4 patients and dural tear in 1 in open-group (9.1%), and residual disc herniation in 2 patients and transient weakness in 1 in split-group (8.8%).

Conclusion

Splitting versus opening LF in PEID may be left to the surgeon’s discretion. The potential risks and benefits of LF handling should be considered when performing this surgical technique in PEID.

Predictors for Poor Outcomes After Percutaneous Endoscopic Lumbar Discectomy: A Retrospective Study of 241 Patients

OBJECTIVE

Percutaneous endoscopic lumbar discectomy (PELD) is a popular surgical procedure for the treatment of lumbar disc herniation (LDH). However, a small proportion of patients will have poor surgical outcomes. We sought to identify the predictors for poor outcomes after PELD.

METHODS

A total of 241 patients who had undergone PELD were followed up. Their numerical rating scale (NRS) for pain and Oswestry Disability Index scores were analyzed. They were divided by outcome (excellent, good, fair, poor) using the MacNab criteria. Their clinical history, physical examination, imaging, and surgical findings were compared among the groups. Ordinal logistic regression analysis was used to identify independent predictors for poor outcomes.

RESULTS

The preoperative mean total NRS for back pain, NRS for leg pain, and Oswestry Disability Index scores were 4.3 ± 2.6, 5.6 ± 2.5, and 52.1% ± 23.0%. At 2 years after PELD, the corresponding scores had decreased to 1.2 ± 1.7, 0.9 ± 1.5, and 8.4% ± 11.2% (P < 0.001). The excellent, good, fair, and poor outcome rates were 44.4%, 31.5%, 17.4%, and 6.6%, respectively. Ordinal logistic regression analysis revealed that 2-level PELD (P = 0.001), a history of lumbar fusion (P = 0.007), and Modic changes (P = 0.011) were independent predictors for poor outcomes. Numbness was an independent predictor for excellent outcomes (P = 0.014).

CONCLUSIONS

PELD appears to be an effective surgery for LDH. Two-level PELD, a history of lumbar fusion, and Modic changes at the same level were independent predictors for poor outcomes after PELD. Patients with LDH with numbness were more likely to have excellent outcomes.

DEGREE OF SATISFACTION WITH THE ENDOSCOPIC TREATMENT OF LUMBAR DISC HERNIATION

ABSTRACT Objective: To evaluate the degree of patient satisfaction and complications after endoscopic surgery for the treatment of lumbar disc herniation. Methods: We retrospectively evaluated 94 patients with lumbar disc herniation undergoing endoscopic lumbar discectomy through the MacNab questionnaire and four subjective questions related to the procedure. Results: Approximately 82% of the patients had good and excellent results, and 91.4% reported being satisfied with the surgical result obtained with endoscopy. The rate of complications with the method was 9.5%, with recurrent disc herniation being the most common complication (5.4% of cases). Conclusions: Endoscopic surgery proved to be an effective and safe method, and an alternative to conventional open surgery. Level of evidence; III. Therapeutic studies - Investigation of treatment results.

The evolution of minimally invasive spine surgery

The field of minimally invasive spine surgery (MISS) has rapidly evolved over the past 3 decades. This review follows the evolution of techniques and principles that have led to significant advances in the field. While still representing only a subset of spine surgeries, MISS’s goals of reducing soft-tissue trauma and mitigating the morbidity of surgery are being realized, translating into more rapid recovery, lower infection rates, and higher cost savings. Future advances in technology and techniques can be anticipated.

Percutaneous Endoscopic Lumbar Diskectomy for Axillar Herniation at L5-S1 via the Transforaminal Approach Versus the Interlaminar Approach: A Prospective Clinical Trial

OBJECTIVE

To evaluate the results of percutaneous endoscopic transforaminal diskectomy (PETD) in comparison with percutaneous endoscopic interlaminar diskectomy (PEID) for axillar herniation at L5-S1.

METHODS

From January 2017 to March 2018, 80 patients admitted with axillar herniation at L5-S1 were randomly recruited into 2 groups: 40 cases in the PETD group and 40 in the PEID group. Each group separately underwent PETD or PEID. Patient sex, age, body mass index, axillar herniation size, number of C-arm fluoroscopies, operation time, postoperative bed time, complications, and clinical effect were compared. Both groups were followed-up using the Oswestry Disability Index (ODI), visual analog scale (VAS), and Macnab criteria.

RESULTS

Except for 1 case in the PETD group that switched to the PEID group, the patients completed the study as expected. All patients were followed-up. Preoperative demographics were not significantly different (P > 0.05) between the 2 groups. The mean number of C-arm fluoroscopies (12.44 ± 3.21) and the operation time (66.49 ± 16.29 minutes) of the PETD group were significantly improved compared with the PEID group (number of fluoroscopies: 3.41 ± 0.81, P < 0.001; operation time: 53.56 ± 10.82 minutes, P < 0.001), but the postoperative bed rest time and complication rate were not (P > 0.05). The postoperative ODI and VAS scores were obviously improved in both groups when compared with preoperation (P < 0.001). There were no significant differences between the 2 groups in the Macnab criteria or VAS and ODI scores at the same time point (P > 0.05).

CONCLUSIONS

For axillar herniation at L5-S1, PEID can ignore the anatomic obstruction with advantages including a shorter operation time and less intraoperative radiation exposure. PETD has a clinical effect similar to that of PEID, but the process of it is more dangerous and harder than PEID.

Feasibility of Full Percutaneous Segmental Stabilization of the Lumbar Spine With a Combination of an Expandable Interbody Cage and an Interspinous Spacer: Preliminary Results

Introduction

We evaluated the feasibility of a full percutaneous approach with an expandable interbody cage and an interspinous spacer for a segmental stabilization of the anterior and posterior columns of the lumbar spine, respectively, with local anesthesia.

Methods

Patients were prospectively included between 2012 and 2018 in this single-center, feasibility case series. An expandable interbody cage was inserted with endoscopy-based, facet-sparing percutaneous transforaminal lumbar interbody fusion (pTLIF). An interspinous spacer was percutaneously placed through the same skin incision. Pre- and postoperative Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) outcomes at 1, 3, 6, 12, and 24 months were obtained and evaluated with the Student t test. Postoperative outcome was classified according to modified Macnab criteria.

Results

A total of 16 patients were included, presenting mean preoperative scores for VAS back of 6.9 ± 2.5, VAS leg 7.9 ± 1.2, and ODI 30.1 ± 4.5. Postoperative mean scores for VAS back of 1.9 ± 2.1, VAS leg 2.1 ± 3.4, and ODI 14.8 ± 13.0 significantly (P < .001) decreased with a mean follow-up of 18.1 ± 16.6 months (range 1-65.2). Postoperative outcome was excellent and good for 13 (81%) cases, fair for 2 (13%), and poor for 1 (6%) case with a preoperative spondylolisthesis, which required revision surgery due to persisting instability. Postoperative complications included 3 cases with transitory, ipsilateral dysesthesia and 2 cases with radiologic cage subsidence but no clinical symptoms. Median postoperative time until hospital discharge was 16 hours.

Conclusion

Our preliminary results for this full percutaneous technique show a similar outcome compared to conventional surgery with a fast patient recovery and early postoperative hospital discharge, opening the way to instrumented, outpatient surgery.

Early Clinical Results of Percutaneous Endoscopic Transforaminal Lumbar Interbody Fusion: A New Modified Technique for Treating Degenerative Lumbar Spondylolisthesis

INTRODUCTION

Lumbar interbody fusion is used to treat degenerative lumbar spondylolisthesis with instability. We developed a device that safely expands a percutaneous path through Kambin's triangle and used it via a new technique: percutaneous endoscopic transforaminal lumbar interbody fusion (PETLIF). We report in this study the details and outcomes of this procedure after a one year follow-up.

METHODS

Twenty-five patients requiring interbody fusion for degenerative spondylolisthesis of the L4 vertebra were enrolled in this study. The procedure involved percutaneous posterior pedicle screw placement to correct spondylolisthesis. After the exterior of the L5 vertebra superior articular protrusion was shaved with a percutaneous endoscopic drill in order to expand the safe zone, the oval sleeve was inserted through Kambin's triangle and was rotated to expand the disk height and create a path toward the vertebral disk. The interbody cage was inserted against the J-shaped nerve retractor, with the exiting nerve root retracted. Indirect decompression of spinal canal stenosis was expected because the vertebral body spondylolisthesis had been corrected and the interbody distance was expanded. Thus, no direct decompression was performed posterolaterally.

RESULTS

The mean follow-up period, surgery time, and blood loss were 22.7 months, 125.4 min, and 64.8 mL, respectively. The Japanese Orthopaedic Association score improved from 13.3 to 28.0. The Roland-Morris Disability Questionnaire score improved from 10.3 to 3.3. All items were evaluated both preoperatively and one year postoperatively. Bone fusion was observed one year postoperatively in 22 out of 25 patients.

CONCLUSIONS

These results demonstrate the feasibility and efficacy of PETLIF for treating degenerative lumbar spondylolisthesis. This minimally invasive procedure is useful and has wide applicability. To obtain safe and favorable results, necessary surgical techniques must be mastered, and surgical equipment, including that for neural monitoring, is required.

Full-Endoscopic Lumbar Discectomy for Lumbar Disc Herniation with Posterior Ring Apophysis Fracture: A Retrospective Study

OBJECTIVE

The present retrospective study evaluated the clinical results of full-endoscopic lumbar discectomy (FELD) for the treatment of lumbar disc herniation (LDH) with lumbar posterior ring apophysis fracture (PRAF) using an interlaminar or a transforaminal approach at an inpatient surgery center.

METHODS

Patients with single-level LDH with type III PRAF who had undergone FELD using an interlaminar or a transforaminal approach from January 2010 to December 2015 were enrolled. The general data recorded included sex, age, location, surgical approach, operative time, hospital stay, perioperative complications, and recurrence. The presence of mobile and immobile fragments was documented. The clinical outcomes were evaluated using a visual analog scale for low back and leg pain. The Oswestry Disability Index was used for the functional assessment and the modified MacNab criteria for patient satisfaction.

RESULTS

FELD was performed successfully in all cases and no serious perioperative complications were observed. A mobile fragment of PRAS was present in 18 patients and an immobile fragment in 15 patients. Complications occurred in 2 of the 33 included patients; 1 dual tear (3.0%) and 1 transient dysesthesia (3.0%) that did not require further treatment. Recurrence developed in 1 patient (3.0%) and required reoperation. The visual analog scale and Oswestry Disability Index scores had significantly improved postoperatively at 3, 6, and 12 months and the final follow-up visit (P < 0.05). Using the modified MacNab criteria, an excellent or good rate of 93.4% was achieved.

CONCLUSIONS

FELD is a safe and effective minimally invasive approach for the treatment of LDH with type III PRAF. Sufficient preparation and experience are required to achieve satisfactory results.

Working Cannula-Based Endoscopic Foraminoplasty: A Technical Note

Purpose

Percutaneous endoscopic lumbar discectomy (PELD) is a minimally invasive disc surgery that can be performed under local anesthesia and requires only an eight-mm skin incision. For the patients with lumbar foraminal stenosis, the migrated disc is difficult to remove with a simple transforaminal approach. In such cases, the foraminoplasty techniques can be used. However, obtaining efficient foramen enlargement while minimizing radiation exposure and protecting the nerves can be challenging.

Methods

In this study, we propose a new technique called the Kiss-Hug maneuver. Under endoscopic viewing, we used the bevel tip of a working cannula as a bone reamer to enlarge the foramen. This allowed us to efficiently enlarge the lumbar foramen endoscopically without the redundancy and complications associated with reamers or trephines.

Results

Details of the four steps of the Kiss-Hug maneuver are reported along with adverse events. The advantages of this new technique include minimizing radiation exposure to both the surgeon and the patient and decreasing the overall operation time.

Conclusion

The endoscopic Kiss-Hug maneuver is a useful and reliable foraminoplasty technique that can enhance the efficiency of foraminoplasty while ensuring patient safety and reducing radiation exposure.

Comparison of percutaneous endoscopic lumbar discectomy versus microendoscopic discectomy for the treatment of lumbar disc herniation: a meta-analysis

PURPOSE

We conducted a systematic review and meta-analysis to compare the clinical outcomes of percutaneous endoscopic lumbar discectomy (PELD) and microendoscopic discectomy (MED) for the treatment of lumbar disc herniation (LDH), and to clarify whether PELD is more superior to MED.

METHODS

We performed a comprehensive search in the databases of MEDLINE, EMBASE, PubMed, Web of Science, Cochrane database, CNKI, and Wanfang Data to acquire all relevant studies up to July 2018. The searched literatures were then screened according to the strict inclusion and exclusion criteria. The critical data were extracted and analyzed utilizing Review Manager software. The pooled effects were calculated by mean difference (MD) or odds ratio (OR) with 95% confidence intervals (CI) on the basis of data attributes.

RESULTS

A total of 18 studies (2161 patients, 1093 in the PELD group and 1068 in the MED group) were included in this systematic review and meta-analysis. At last follow-up, the results revealed that no significant difference was found between PELD group and MED group with respect to ODI (MD - 0.30; 95% CI - 1.02 to 0.42; P = 0.41), VAS-leg pain (MD - 0.18; 95% CI - 0.45 to 0.09; P = 0.19), VAS-unspecified (MD - 0.00; 95% CI - 0.05 to 0.04; P = 0.94), excellent & good rate (OR, 1.04; 95% CI 0.68 to 1.59; P = 0.86), total complication rate (OR, 0.96; 95% CI 0.65 to 1.43; P = 0.85), dural tear rate (OR, 0.39; 95% CI 0.10 to 1.55; P = 0.18), and residue or recurrence rate (OR, 2.22; 95% CI 1.02 to 4.83; P = 0.05). When compared to MED group, the PELD group showed significantly better results with regard to shorter length of incision (MD - 1.18; 95% CI - 1.39 to - 0.97; P < 0.00001), less blood loss (MD - 45.17; 95% CI - 64.74 to - 25.60; P < 0.00001), shorter post-operative in-bed time (MD - 59.11; 95% CI - 71.19 to - 47.04; P < 0.00001), shorter post-operative hospital stay (MD - 3.07; 95% CI - 4.81 to - 1.33; P < 0.00001), shorter total hospital stay (MD - 2.29; 95% CI - 3.03 to - 1.55; P < 0.00001), and lower VAS-back pain at last follow-up (MD - 0.77; 95% CI - 1.31 to - 0.24; P = 0.005), but with significantly worse results such as more fluoroscopy (MD 7.63; 95% CI 5.25 to 10.01; P < 0.00001) and higher re-operation rate (OR, 2.67; 95% CI 1.07 to 6.67; P = 0.04). Although no significant difference was found between the two groups in terms of duration of operation (MD 6.27; 95% CI - 2.44 to 14.98; P = 0.16) and total hospital cost (MD - 0.69; 95% CI - 12.60 to 11.23; P = 0.91), further subgroup analysis revealed that the duration of operation was significantly longer in the PELD group compared with the MED group in "Years before 2016" (MD 24.97; 95% CI 7.07 to 42.87; P = 0.006) and "Year 2016 to 2017" (MD 6.57; 95% CI 0.58 to 12.55; P = 0.03) subgroups but not in the subgroup "Year 2018" (MD - 5.66; 95% CI - 18.84 to 7.53; P = 0.40), and that the total hospital cost was significantly more in the PELD group compared with the MED group in the subgroup "Southeast of China" (MD 6.67; 95% CI 3.23 to 10.28; P = 0.0002) but not in the subgroup "Midwest of China" (MD - 8.09; 95% CI - 17.99 to 1.80; P = 0.11).

CONCLUSIONS

For the treatment of LDH, both of PELD and MED can reach excellent results and no superiority was found between the two minimally invasive procedures with regard to duration of operation, ODI, VAS-leg pain, VAS-unspecified, excellent & good rate, total complication rate, dural tear rate, and residue or recurrence rate. While PELD can achieve better outcomes with respect to the length of incision, blood loss, post-operative in-bed time, post-operative hospital stay, total hospital stay, and VAS-back pain at last follow-up, however, MED showed certain advantages of less fluoroscopic times and lower re-operation rate. More practice and development are needed to make up for the deficiencies of PELD. Besides, the economic factor should also be considered according to different regions before making the treatment strategies. Well-defined randomized controlled trials with large samples are needed to further confirm these results.

[The trend towards full-endoscopic decompression : Current possibilities and limitations in disc herniation and spinal stenosis]

BACKGROUND

The most frequent causes of degenerative constrictions of the spinal canal are disk herniations and spinal stenoses. The lumbar and cervical spine is the most affected.

SURGICAL PROCEDURES

After conservative treatments have been exhausted, surgical intervention may be necessary. Today, microsurgical decompression is regarded as the standard procedure in the lumbar region, while in the cervical spine, microsurgical anterior decompression and fusion are standard. Full-endoscopic techniques for decompression are becoming increasingly widespread worldwide. The development of various surgically created approaches and appropriate instrument sets have made the full-endoscopic operation of disk herniations and spinal stenosis possible. This development has also permitted resection of soft disk herniations in the cervical spine. The use of the approaches depends on anatomical and pathological inclusion and exclusion criteria.

RESULTS

The clinical results of standard procedures have been achieved, which must be regarded as a minimum criterion for the introduction of new technologies. On the basis of EBM criteria, it can be established that using the full-endoscopic techniques developed, adequate decompression is achieved in the defined indications with reduced traumatization, improved visibility conditions, and positive cost benefits. Today, full-endoscopic operations may be regarded as an expansion and alternative within the overall concept of spinal surgery.

Intraoperative Disc Prolapse During Percutaneous Endoscopic Lumbar Discectomy

BACKGROUND

Percutaneous endoscopic lumbar discectomy (PELD) is regarded as an alternative treatment for lumbar disc herniation. Although the indication for PELD has expanded with remarkable evolution of the technique, sometimes unexpected complications have occurred during PELD. We report 3 cases of de novo disc prolapse during PELD.

CASE DESCRIPTION

In 3 patients who underwent PELD for lumbar disc herniation with local anesthesia, postoperative magnetic resonance imaging demonstrated newly developed up-migrated disc herniation. Compared with their preoperative states, these patients experienced decreased intensity of both leg and back pain. There were no neurologic deficits. PELD was repeated for L1-L2 disc herniation only to relieve compression of the conus medullaris.

CONCLUSIONS

Although the incidence was very low (0.3%) and the lesions were nonsymptomatic, de novo disc prolapse may be associated with an inside-out PELD technique. Discography and insertion of the obturator should be handled gently. The possibility of de novo disc prolapse should be kept in mind when performing PELD.

The full-endoscopic uniportal technique for decompression of the anterior craniocervical junction using the retropharyngeal approach: an anatomical feasibility study in human cadavers and review of the literature

Objective

Acute or progressive myelopathy may necessitate direct anterior decompression of the craniocervical junction and odontoidectomy. Different techniques with individual advantages and disadvantages can be used. In addition to the gold standard-the transoral approach-there is also increasing experience with the endoscopic transnasal technique. Other alternative methods are also being developed to reduce technical and perioperative problems. The aim of this anatomical study was to investigate the feasibility of the full-endoscopic uniportal technique with a retropharyngeal approach for decompression of the craniocervical junction, taking into consideration the specific advantages and disadvantages compared with conventional methods and the currently available data in the literature.

Methods

Five fresh adult cadavers were operated on. The endoscope used has a shaft cross-section of 6.9 × 5.9 mm and a 25° viewing angle. It contains an eccentric intraendoscopic working channel with a diameter of 4.1 mm. An anterior retropharyngeal approach was used. The anatomical structures of the anterior craniocervical junction were dissected and the bulbomedullary junction was decompressed.

Results

The planned steps of the operation were performed in all cadavers. The retropharyngeal approach allowed the target region to be accessed easily. The anatomical structures of the anterior craniocervical junction could be identified and dissected. The bulbomedullary junction could be adequately decompressed. No resections of the anterior arch of the atlas were necessary in the odontoidectomy.

Conclusions

Using the full-endoscopic uniportal technique with an anterior retropharyngeal approach, the craniocervical region can be adequately reached, dissected, and decompressed. This is a minimally invasive technique with the known advantages of an endoscopic procedure under continuous irrigation. The retropharyngeal approach allows direct, sterile access. The instruments are available for clinical use and have been established for years in other operations of the entire spine.

Unilateral Biportal Endoscopic Spinal Surgery Using a 30° Arthroscope for L5-S1 Foraminal Decompression

Foraminal decompression using a minimally invasive technique to preserve facet joint stability and function without fusion reportedly improves the radicular symptoms in approximately 80% of patients and is considered one of the good surgical treatment choices for lumbar foraminal or extraforaminal stenosis. However, proper decompression was not possible because of the inability to access the foramen at the L5–S1 level due to prominence of the iliac crest. To overcome this challenge, endoscopy-based minimally invasive spine surgery has recently gained attention. Here, we report the technical skills required in unilateral extraforaminal biportal endoscopic spinal surgery using a 30° arthroscope to enable foraminal decompression at the L5–S1 level. Two 0.8-cm portals were created 2 cm lateral from the lateral border of the pedicles at the L5–S1 level. After sufficient working space was made, half of the superior articular process (SAP) in the hypertrophied facet joint was removed using a high-speed burr and a 5-mm wide osteotome, whereas the remaining inside part of the SAP was removed using a Kerrison punch and pituitary punch. The foraminal ligamentum flavum should be removed to inspect the conditions of the L5 exiting root and disc. Removing of the extruded disc could decompress the L5 root. The extraforaminal approach using a 30° arthroscope is considered a minimally invasive alternative technique for decompressing foraminal stenosis at the L5–S1 level that preserves facet stability and provides symptomatic relief.

Clinical and Radiological Outcomes of Foraminal Decompression Using Unilateral Biportal Endoscopic Spine Surgery for Lumbar Foraminal Stenosis

Background

Since open Wiltse approach allows limited visualization for foraminal stenosis leading to an incomplete decompression, we report the short-term clinical and radiological results of unilateral biportal endoscopic foraminal decompression using 0° or 30° endoscopy with better visualization.

Methods

We examined 31 patients that underwent surgery for neurological symptoms due to lumbar foraminal stenosis which was refractory to 6 weeks of conservative treatment. All 31 patients underwent unilateral biportal endoscopic far-lateral decompression (UBEFLD). One portal was used for viewing purpose, and the other was for surgical instruments. Unilateral foraminotomy was performed under guidance of 0° or 30° endoscopy. Clinical outcomes were analyzed using the modified Macnab criteria, Oswestry disability index, and visual analogue scale. Plain radiographs obtained preoperatively and 1 year postoperatively were compared to analyze the intervertebral angle (IVA), dynamic IVA, percentage of slip, dynamic percentage of slip (gap between the percentage of slip on flexion and extension views), slip angle, disc height index (DHI), and foraminal height index (FHI).

Results

The IVA significantly increased from 6.24° ± 4.27° to 6.96° ± 3.58° at 1 year postoperatively (p = 0.306). The dynamic IVA slightly decreased from 6.27° ± 3.12° to 6.04° ± 2.41°, but the difference was not statistically significant (p = 0.375). The percentage of slip was 3.41% ± 5.24% preoperatively and 6.01% ± 1.43% at 1-year follow-up (p = 0.227), showing no significant difference. The preoperative dynamic percentage of slip was 2.90% ± 3.37%; at 1 year postoperatively, it was 3.13% ± 4.11% (p = 0.720), showing no significant difference. The DHI changed from 34.78% ± 9.54% preoperatively to 35.05% ± 8.83% postoperatively, which was not statistically significant (p = 0.837). In addition, the FHI slightly decreased from 55.15% ± 9.45% preoperatively to 54.56% ± 9.86% postoperatively, but the results were not statistically significant (p = 0.705).

Conclusions

UBEFLD using endoscopy showed a satisfactory clinical outcome after 1-year follow-up and did not induce postoperative segmental spinal instability. It could be a feasible alternative to conventional open decompression or fusion surgery for lumbar foraminal stenosis.

Open Discectomy vs. Microdiscectomy: Results from 519 Patients Operated for Lumbar Disc Herniation

Objective

The aim of this study was to evaluate the outcomes of patients with lumbar disk hernia operated between 2012 January and 2017 August and to compare the differences between open discectomy (OD) and microdiscectomy (MD).

Materials and Methods

Files of 519 patients who presented at our neurosurgical department with lumbar disk herniation were retrospectively reviewed and recorded. Preoperatively, all patients routinely underwent spinal lumbar magnetic resonance imaging (MRI) and anteroposterior as well as lateral lumbar vertebrae X-rays. During the early postoperative period, there was no need for imaging. Surgical interventions were performed using the two currently accepted OD and MD methods.

Results

We reviewed 519 patients with lumbar disk herniation who were operated in our clinic between 2012 and 2017. The mean age of 276 patients who underwent OD was 44.85±9.92 y, and that of the remaining 243 patients who underwent MD was 47.69±12.87 y. There was no difference in the demographic distributions of patients; levels of lumbar disk herniations; postoperative clinical outcomes; and long-term reoperation rates due to root injury, wound infection, dural tear, or the recurrence of lumbar disk herniation (p>0.05). The duration of operation was significantly shorter for OD (37.82±7.15 vs. 49.07±6.88 min; t=-18.184, p<0.001).

Conclusion

The long-term results of patients who underwent OD and MD for lumbar disk herniation were similar. We believe that both methods can be safely used under appropriate conditions and surgical experience and that surgical experience has an impact on their outcomes.

Outcomes of discectomy by using full-endoscopic visualization technique via the interlaminar and transforaminal approaches in the treatment of L5-S1 disc herniation: An observational study

The purpose of this retrospective study was to assess the clinical outcomes of discectomy by using full-endoscopic visualization technique via the interlaminar approach versus the transforaminal approach under general anesthesia in the treatment of L5-S1 disc herniation.Sixty patients with L5-S1 disc herniation were non-randomly recruited and assigned into two groups. One group (thirty patients) underwent discectomy by using full-endoscopic visualization technique via the interlaminar approach under general anesthesia, while the other group (thirty patients) underwent discectomy by using full-endoscopic visualization technique via the transforaminal approach under general anesthesia. The operative time, fluoroscopy time, and perioperative complications were recorded. The visual analog scale (VAS) score for leg and back pain and Oswestry disability index (ODI) score were evaluated preoperatively and at 3, 6, and 18 months postoperatively.The mean operative time and fluoroscopy time in the interlaminar group were significantly shorter compared with those in the transforaminal group. The mean VAS and ODI postoperative scores were significantly improved over the preoperative scores in both groups. According to the MacNab classification system, more than 90.0% of the patients achieved an excellence/good rating in both groups. An intraoperative epineurium injury occurred in both groups. The total recurrence rate during 18 months follow-up was 3.3% in the interlaminar group and 0% in the transforaminal group.It is efficient and safe to perform discectomy by using full-endoscopic visualization technique via both interlaminar and transforaminal approaches under general anesthesia in patients with L5-S1 disc herniation. Discectomy performed by using full-endoscopic visualization technique via the interlaminar approach requires a shorter operative time and suffers less radiation exposure than the transforaminal approach.

Five-year outcomes and predictive factors of transforaminal full-endoscopic lumbar discectomy

Although several studies have reported the effectiveness of transforaminal full-endoscopic lumbar discectomy (TELD), no cohort study on the long-term outcomes of TELD has been conducted. Thus, this study aimed to evaluate the long-term clinical outcomes of TELD and to determine the factors predicting favorable outcome.Five-year longitudinal data of 204 consecutive patients who underwent TELD were collected. Outcomes were assessed using the visual analog scale (VAS) pain score, Oswestry disability index (ODI), patient satisfaction rating, and the modified Macnab criteria.The mean VAS score for leg pain improved from 7.64 at the baseline to 1.71, 0.81, 0.90, and 0.99 at postoperative 6 weeks, 1 year, 2 years, and 5 years, respectively (P <.001). The mean ODI improved from 67.2% at the baseline to 15.7%, 8.5%, 9.4%, and 10.1% at postoperative 6 weeks, 1 year, 2 years, and 5 years, respectively (P <.001). The overall patient satisfaction rate was 94.1%. Based on the modified Macnab criteria, 83.8% of patients had excellent or good results. In this study, younger patients with intracanal disc herniation tended to have better outcomes than elderly patients with foraminal/far-lateral disc herniation (P <.05).Transforaminal endoscopic lumbar discectomy offers favorable long-term outcomes with minimal tissue damage. Postoperative pain and functional status may change over time. Proper patient selection remains essential for the success of this minimally invasive procedure.

Lumbar herniated disc - endoscopic discectomy treatment

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

Outcomes of percutaneous endoscopic trans-articular discectomy for huge central or paracentral lumbar disc herniation

PURPOSE

This study reports a new technique known as percutaneous endoscopic trans-articular discectomy (PETAD) for huge central/paracentral lumbar disc herniation (LDH).

METHODS

Sixteen patients with huge central/paracentral LDH who underwent PETAD in our department from July 2015 to July 2016 were retrospectively analyzed. Clinical outcomes were evaluated according to pre-operative and post-operative visual analog scale (VAS) and Oswestry disability index (ODI) scores and the MacNab criteria. Immediate post-operative MRI and CT were conducted to confirm complete removal of LDH along with follow-up flexion-extension X-ray to observe lumbar stability.

RESULTS

The huge central/paracentral LDH was completely removed by PETAD in 16 patients, as confirmed by post-operative MRI and CT. Leg pain was eased after removal of the disc herniations. The satisfactory (excellent/good) results were 93.7%. The mean follow-up duration was 15.6 (range, 3-24) months. The mean pre-operative VAS and ODI scores were 5.72 ± 1.18 (range, 4-9) and 60.1 (range, 51-87), respectively, which decreased to 1.26 ± 0.81 (range, 0-3) and 18.1 (range, 10-31), respectively at the third month post-operatively and to 0.78 ± 0.62 (range, 0-1) and 7.2 (range, 0-15), respectively by the last follow-up visit. No recurrence and segmental instability was observed in any of the 16 patients during the follow-up period.

CONCLUSION

PETAD could be a good alternative for treatment of huge central/paracentral LDH.

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.

Percutaneous Endoscopic Lumbar Discectomy Versus Posterior Open Lumbar Microdiscectomy for the Treatment of Symptomatic Lumbar Disc Herniation: A Systemic Review and Meta-Analysis

OBJECTIVE

The purpose of this systematic review and meta-analysis was to compare the clinical efficacy between percutaneous endoscopic lumbar discectomy (PELD) versus posterior open lumbar microdiscectomy (OLMD) for the treatment of symptomatic lumbar disc herniation.

METHODS

We performed a comprehensive retrieval of related studies in 4 electronic databases (PubMed, Embase, Web of Science, and the Cochrane Library). Randomized or nonrandomized controlled trials reported from January 1990 to December 2017 that compared PELD versus OLMD for the treatment of symptomatic lumbar disc herniation were acquired. The quality of randomized controlled trials was evaluated by the criteria of the Cochrane Back Review Group, and the quality of cohort studies was assessed according to the Newcastle-Ottawa Scale. The primary outcome measurements included preoperative and postoperative visual analog scale (VAS) score of sciatica; the Oswestry Disability Index (ODI) before and after surgery; the Excellent and Good outcome rate based on Macnab criteria. The secondary outcome measurements included the incidence of complication, residual disk, recurrence, and reoperation; operation time; hospital stay; and time to return to work. Two authors independently extracted data and assessed each study for quality.

RESULTS

Nine studies with 1585 patients were included in our meta-analysis. Two were randomized controlled trials and the remaining 7 were retrospective cohort studies. The forest plots showed that no statistically significant difference was observed between the 2 groups in terms of preoperative and postoperative VAS score of sciatica, ODI before and after surgery, the Excellent and Good outcome rate, the complication rate, and the incidence of recurrence and reoperation. However, the PELD group had a higher incidence of residual disk or incomplete decompression than did the OLMD group. In addition, no significant difference was detected in the operation time between the 2 groups, but the PELD group was associated with shorter hospital stay and time of return to work.

CONCLUSIONS

Based on the present meta-analysis, no significant difference existed in VAS and ODI scores between the 2 surgical procedures, and they were also similar in terms of operation time, complication rate, and incidence of recurrence and reoperation, but PELD showed shorter hospital stay and time of return to work. Thus, under the premise of careful manipulation and complete decompression, we consider that PELD is a relatively more minimally invasive technique, which could be an alternative to OLMD.