Comparison of percutaneous endoscopic lumbar discectomy versus open lumbar microdiscectomy for lumbar disc herniation: A meta-analysis. Int J Surg. 2016;31:86-92. [PMID: 27260312 DOI: 10.1016/j.ijsu.2016.05.061]

Is Close Supervision by a Senior Surgeon Necessary During the Initial Days of Performing Endoscopic Lumbar Discectomy? A Retrospective Comparative Study between Two Fellowship Trained Surgeons to Assess the Learning Curve

Objectives

Endoscopic lumbar discectomy is a minimally invasive technique with a steep learning curve. The studies in the literature base the learning curve on the operative duration. We conducted this study to determine the learning curve based on the presence or absence of supervision by an experienced surgeon.

Materials and Methods

This study involved two spine surgeons (surgeon A and surgeon B), who after their fellowship training from the same institute started practising in two different hospitals with different settings. The data of the first 80 patients operated by these two surgeons were extracted, and the patients were followed up for a minimum of 1 year. The data were split into first 30 cases and late 50 cases, which were compared to see the difference between the two surgeons.

Results

The first 30 cases were evaluated between the two surgeons, and the most significant difference between the two was the operative duration. There was difference between the two surgeons in approach towards migrated and foraminal/extra foraminal discs (P = 0.02). The surgeon B started operating on upper lumbar levels in his later 50 cases, but the foraminal and extraforaminal disc herniations were rarely treated by surgeon B.

Conclusions

Endoscopic discectomy when supervised by senior faculty helps to reduce the operative duration especially in the initial phases of a surgeon's career. The surgeon under the supervision of a senior faculty performs more of migrated and foraminal herniated discs.

Fatty Infiltration in Paraspinal Muscles: Predicting the Outcome of Lumbar Surgery and Postoperative Complications

Lumbar spine disorders often cause lower back pain, lower limb radiating pain, restricted movement, and neurological dysfunction, which seriously affect the quality of life of middle-aged and older people. It has been found that pathological changes in the spine often cause changes in the morphology and function of the paraspinal muscles (PSMs). Fatty infiltration (FI) in PSMs is closely associated with disc degeneration and Modic changes. And FI causes inflammatory responses that exacerbate the progression of lumbar spine disease and disrupt postoperative recovery. Magnetic resonance imaging can better distinguish between fat and muscle tissue with the threshold technique. Three-dimensional magnetic resonance imaging multi-echo imaging techniques such as water-fat separation and proton density are currently popular for studying FI. Muscle fat content obtained based on these imaging sequences has greater accuracy, visualization, acquisition speed, and utility. The proton density fat fraction calculated from these techniques has been shown to evaluate more subtle changes in PSMs. Magnetic resonance spectroscopy can accurately reflect the relationship between FI and the degeneration of PSMs by measuring intracellular and extracellular lipid values to quantify muscle fat. We have pooled and analyzed published studies and found that patients with spinal disorders often exhibit FI in PSMs. Some studies suggest an association between FI and adverse surgical outcomes, although conflicting results exist. These suggest that clinicians should consider FI when assessing surgical risks and outcomes. Future studies should focus on understanding the biological mechanisms underlying FI and its predictive value in spinal surgery, providing valuable insights for clinical decision-making.

Natural Language Processing-Driven Artificial Intelligence Models for the Diagnosis of Lumbar Disc Herniation with L5 and S1 Radiculopathy: A Preliminary Evaluation

OBJECTIVE

To develop and validate natural language processing-driven artificial intelligence (AI) models for the diagnosis of lumbar disc herniation (LDH) with L5 and S1 radiculopathy using electronic health records (EHRs).

METHODS

EHRs of patients undergoing single-level percutaneous endoscopic lumbar discectomy for the treatment of LDH at the L4/5 or L5/S1 level between June 1, 2013, and December 31, 2021, were collected. The primary outcome was LDH with L5 and S1 radiculopathy, which was defined as nerve root compression recorded in the operative notes. Datasets were created using the history of present illness text and positive symptom text with radiculopathy (L5 or S1), respectively. The datasets were randomly split into a training set and a testing set in a 7:3 ratio. Two machine learning models, the long short-term memory network and Extreme Gradient Boosting, were developed using the training set. Performance evaluation of the models on the testing set was done using measures such as the receiver operating characteristic curve, area under the curve, accuracy, recall, F1-score, and precision.

RESULTS

The study included a total of 1681 patients, with 590 patients having L5 radiculopathy and 1091 patients having S1 radiculopathy. Among the 4 models developed, the long short-term memory model based on positive symptom text showed the best discrimination in the testing set, with precision (0.9054), recall (0.9405), accuracy (0.8950), F1-score (0.9226), and area under the curve (0.9485).

CONCLUSIONS

This study provides preliminary validation of the concept that natural language processing-driven AI models can be used for the diagnosis of lumbar disease using EHRs. This study could pave the way for future research that may develop more comprehensive and clinically impactful AI-driven diagnostic systems.

Full-Endoscopic Posterior Lumbar Interbody Fusion: A Review and Technical Note

Remarkable innovations in spinal endoscopic surgery have broadened its applications over the past 20 years. Full-endoscopic fusions have been widely reported, and several full-endoscopic approaches for interbody fusion have been published. In general, full-endoscopic lumbar interbody fusion (LIF) is called Endo-LIF, and facet-preserving Endo-LIF through the transforaminal route is called trans-Kambin's triangle LIF, which has a relatively longer history than facet-sacrificing Endo-LIF via the posterolateral route. Both approaches can reduce intraoperative and postoperative bleeding. However, there is a higher risk of subsidence and exit nerve root injury. There is no direct decompression in either of the interbody fusions, and additional decompression is required if there is severe lumbar bony canal stenosis. However, the posterior interlaminar approach, which is a well-known standard in full-endoscopic spine surgery, has rarely been applied in the field of endoscopic lumbar fusion surgery. Full-endoscopic posterior LIF (FE-PLIF) via an interlaminar approach can accomplish direct decompression of bony canal stenosis and safe interbody fusion. FE-PLIF via an interlaminar approach demonstrated a longer operation time, less blood loss, and shorter hospitalization duration than minimally invasive transforaminal LIF. FE-PLIF, which can accomplish direct decompression for bony spinal canal stenosis, is superior to other Endo-LIFs. However, FE-PLIF requires technical dexterity to improve efficiency and reduce technical complexity.

Endoscopic Treatment of Lumbar Degenerative Disc Disease: A Narrative Review of Full-Endoscopic and Unilateral Biportal Endoscopic Spine Surgery

BACKGROUND

Degenerative lumbar spine disease is the leading cause of disability and work absenteeism worldwide. Lumbar microdiscectomy became the standard treatment for herniated discs and stenotic disease. With the evolution of different techniques, endoscopic spinal surgery emerged to minimize the surgical footprint while providing at least non-inferior results. Currently, two different types of endoscopic spine procedures are dominating the surgical scenario: "Full-Endoscopic" (FE) and Unilateral Biportal Endoscopic" (UBE) Spine Surgery. The aim of this study is to describe and analyze their indications, their technical characteristicswithitsadvantagesanddisadvantagesofbothtechniquesandtheirfuture trends.

METHODS

We performed a narrative review of the most relevant articles published up to August 2023 through a Pub Med search. The search terms " FE Spine Surgery" and " UBE Spine Surgery" were used. The articles selected, were independently reviewed by 3 authors and 55 full text articles were reviewed.

RESULTS

The FE and UBE Spine Surgery techniques were described. The FE technique is performed with a monoportal access under constant saline irrigation. The FE comprises the transforaminal and the interlaminar approaches, and the indication depends from the pathology to treat, and still remains controversial. UBE can approach also the spine from a posterior, postero lateral,and para spinal route. It uses two different ports addressed to a target with continuous irrigation. The process of establishing these two portals is called triangulation.

CONCLUSIONS

FE and UBE spine surgery have demonstrated outcomes comparable to open surgery, minimizing complications and surgical footprint.

Comparing the Efficacy and Safety of Unilateral Biportal Endoscopic Decompression with Percutaneous Endoscopic Lumbar Decompression for Lumbar Degenerative Diseases: A Meta-Analysis

OBJECTIVE

Unilateral biportal endoscopic decompression (UBED) offers the advantages of minimal tissue damage, operational flexibility, and clear visualization, positioning it as an innovative and minimally invasive endoscopic technique. Nevertheless, the clinical evidence supporting the use of UBED in the treatment of degenerative lumbar diseases is limited and conflicting.

METHODS

As of October 1, 2023, a comprehensive search was conducted across databases including Web of Science, PubMed, Embase, and the Cochrane Library to identify all published studies on minimally invasive UBED for the treatment of degenerative lumbar diseases. Data pertaining to patient demographics, fluoroscopy time, operative duration, intraoperative hemorrhage, hospitalization length, visual analog scale (VAS) score for back and leg pain, MacNab criteria, Oswestry Disability Index (ODI), and complication rates were extracted. The Newcastle-Ottawa scale was utilized to assess the quality.

RESULTS

Twelve articles were included, involving 816 patients. The back VAS score (95% confidence interval [CI]: -0.09-0.07, P = 0.75), MacNab criteria (95% CI: 0.52-2.3, P = 0.82), fluoroscopy time (95% CI: -7.03 to -0.4, P = 0.08), and the incidence of complications (95% CI: 0.5-1.73, P = 0.82) were not significantly different, while the leg VAS score (95% CI: 0.01-0.18, P = 0.03), ODI score (95% CI: -1.03 to -0.09, P = 0.02), operation time (95% CI: 5.76-20.62, P = 0.0005), hospitalization length (95% CI: 0.41-2.76, P = 0.008), and intraoperative hemorrhage (95% CI: 21.92-72.44, P = 0.0003) were significantly different.

CONCLUSIONS

UBED offers superiority in ODI, flexibility, and visual field clarity. Conversely, percutaneous endoscopic lumbar decompression presents advantages in terms of operation duration, blood loss, hospitalization length, and leg VAS score. These factors should be thoroughly considered when selecting a surgical approach.

Bibliometric and Visualization Analysis of Research Hotspots and Frontiers in Endoscopic Lumbar Discectomy

Background

The increasing utilization of endoscopic lumbar discectomy (ELD) in spinal surgery has sparked widespread interest and research. This study utilizes bibliometric analysis to identify current research trends and advancements in this innovative surgical technique, with the goal of informing and improving surgical practices.

Methods

We retrieved relevant literature on ELD from the Science Citation Index Expanded (SCI-Expanded) within the Web of Science Core Collection (WoSCC) database as research samples. Various visualization tools, such as VOSviewer, CiteSpace, Scimago Graphica, Pajek, and online bibliometric platform, were employed to generate scientific knowledge maps for the purpose of visual presentation and data analysis.

Results

Over the past two decades, there has been significant progress in the research related to ELD, particularly since 2016. China has emerged as the most productive country, while South Korea and the United States have exerted greater academic influence. Tongji University has contributed the highest number of research output, while academic achievements published by Wooridul Spine Hospital are highly esteemed by scholars. Lee SH and Ruetten S are the most prolific author and the most highly cited author, respectively. World Neurosurg has published the highest number of publications, while Spine has become the most influential journal. Clinical Neurology and Surgery are the primary subject categories. Research in this field primarily revolves around improving ELD techniques, evaluating postoperative efficacy and prognosis prediction, studying complications and risk factors, as well as comparative research with other surgical techniques. Keywords such as risk factors, LDH, PETD, lumbar spinal stenosis, degeneration, recurrent herniation, laminectomy, local anesthesia, and foraminoplasty highlight the current research hotspots and future cutting-edge trends.

Conclusion

This study employed bibliometric analysis to elucidate the research hotspots and frontiers in ELD. The findings have significant implications for advancing research and development in this field.

Unilateral biportal endoscopic discectomy versus microdiscectomy for lumbar disc herniation: a systematic review and meta-analysis

PURPOSE

This study aimed to compare unilateral biportal endoscopic discectomy (UBED) with microdiscectomy (MD) for treating lumbar disk herniation (LDH).

METHODS

A comprehensive literature search was conducted in the Embase, PubMed, Cochrane Library, CNKI, and Web of Science databases from database inception to April 2023 to identify studies comparing UBED and MD for treating LDH. This study evaluated the visual analog scale (VAS) score, Oswestry disability index (ODI), Macnab scores, operation time, estimated blood loss, hospital stay, and complications, estimated blood loss, visual analog scale (VAS) score, Oswestry disability index (ODI), and Macnab scores at various pre- and post-surgery stages. The meta-analysis was performed using RevMan 5.4 software.

RESULTS

The meta-analysis included 9 distinct studies with a total of 1001 patients. The VAS scores for low back pain showed no significant differences between the groups at postoperative 1-3 months (P = 0.09) and final follow-up (P = 0.13); however, the UBED group had lower VAS scores at postoperative 1-3 days (P = 0.02). There were no significant differences in leg pain VAS scores at baseline (P = 0.05), postoperative 1-3 days (P = 0.24), postoperative 1-3 months (P = 0.78), or at the final follow-up (P = 0.43). ODI comparisons revealed no significant differences preoperatively (P = 0.83), at postoperative 1 week (P = 0.47), or postoperative 1-3 months (P = 0.13), and the UBED group demonstrated better ODI at the final follow-up (P = 0.03). The UBED group also exhibited a shorter mean operative time (P = 0.03), significantly shorter hospital stay (P < 0.00001), and less estimated blood loss (P = 0.0002). Complications and modified MacNab scores showed no significant differences between the groups (P = 0.56 and P = 0.05, respectively).

CONCLUSION

The evidence revealed no significant differences in efficacy between UBED and MD for LDH treatment. However, UBED may offer potential benefits such as shorter hospital stays, lower estimated blood loss, and comparable complication rates.

Access to the Lumbosacral Spine: A Current View

The surgical approach to the lumbosacral spine has been the subject of experimental and scientific anatomical studies since the Hippocratic era. However, it was in the 20th century that, with the evolution of asepsis and antibiotic therapy, spine surgery began to evolve at breakneck speed, and the various possibilities of access roads became objects of development and discussion. As a result, pathologies of the lumbosacral spine can be accessed in different ways and positions, from the traditional posterior approach in the prone position to the anterior, oblique, lateral, and endoscopic approaches. The current article brings state-of-the-art access routes to the lumbosacral spine. This article objective is to elucidate the possibilities of accesses the lumbar spine for any purposes, as decompression, fusion, tumour resections, reconstruction or deformity correction, despites type of implants or implants positioning.

Minimally Invasive Treatment for Lumbar Disc Herniation: A Matched Comparison Between Tubular Microdiscectomy and Percutaneous Endoscopic Lumbar Discectomy

Background and objectives Discectomy for lumbar disc herniation is the most common spinal surgical procedure. Technological advances have led to the emergence of minimally invasive surgical approaches such as tubular microdiscectomy (TMD) and percutaneous endoscopic lumbar discectomy (PELD). The purpose of this study was to compare the clinical outcomes of PELD to those of TMD at one-year follow-up. Materials and methods This observational registry-based (Spine Tango) cohort study included patients with symptomatic lumbar disc herniation submitted to PELD or TMD. The inclusion criteria were patients who underwent minimally invasive lumbar discectomy (PELD or TMD), patients who attended a follow-up after a minimum of 12 months post surgery, and valid pre- and postoperative questionaries. The primary endpoint was defined as the difference between pre- and postoperative Core Outcome Measures Index (COMI) for the back. The matching was based on a 1:1 nearest neighbor matching without replacement. Results A total of 109 patients were included in this study. Propensity score matching (PSM) was performed achieving 86 patients in the matched sample. Regarding COMI improvement, we found no significant difference between the PELD and TMD groups (paired t-test: estimate, -0.23; standard error, 0.6; p=0.7), and we also did not find any significant difference between groups concerning Oswestry Disability Index (ODI) and EuroQol 5 Dimension (EQ-5D). Medication usage and return to work were similar among the matched groups. Conclusions PELD is a technique that minimizes tissue damage achieving good clinical outcomes similar to TMD. This was observed one year after surgery from patient-reported outcome measures (PROMs) that measured pain improvement, disability, and quality of life.

Outcome of Percutaneous Endoscopic Lumbar Discectomy in Relation to the Surgeon's Experience: Propensity Score Matching

Percutaneous endoscopic lumbar discectomy (PELD) presents a challenging learning curve, and the correlation between surgeon experience and clinical outcomes remains contentious. This retrospective study aimed to compare the outcomes of PELD performed by a single surgeon at beginner and experienced stages. Propensity score matching selected 150 patients (75 per group) with a minimum 3-year follow-up. Clinical and radiological outcomes, perioperative complications, and adverse events were assessed. Baseline characteristics, pain improvement, patient satisfaction, and radiological outcomes did not differ between the groups. However, operation time was longer in the beginner group than in the experienced group (57.5 min [IQR, 50.0-70.0] versus 50.0 min [IQR, 45.0-55.0], p < 0.001). The beginner group had higher perioperative complication rates (eight patients [10.7%] versus one patient [1.3%], with a hazard ratio of 8.836 [95% CI, 1.077-72.514], p = 0.034) and lower 3-year survival without adverse events (19 patients [25.3%] in the beginner group and 10 patients [13.3%] in the experienced group, p = 0.045). Our findings indicate that the clinical outcomes were more favorable in patients operated on at the experienced stage compared to those treated at the beginner stage.

Evaluation of Spin in Systematic Reviews and Meta-Analyses of Minimally Invasive Surgical Techniques and Standard Microdiscectomies for Treating Lumbar Disc Herniation

STUDY DESIGN

Systematic review.

OBJECTIVES

Spin in scientific literature is defined as bias that overstates efficacy and/or underestimates harms of procedures undergoing review. While lumbar microdiscectomies (MD) are considered the gold standard for treating lumbar disc herniations (LDH), outcomes of novel procedures are being weighed against open MD. This study identifies the quantity and type of spin in systematic reviews and meta-analyses of LDH interventions.

METHODS

A search was conducted on the PubMed, Scopus, and SPORTDiscus databases for systematic reviews and meta-analyses evaluating the outcomes of MD against other LDH interventions. Each included study's abstract was assessed for the presence of the 15 most common types of spin, with full texts reviewed during cases of disagreement or for clarification. Full texts were used in the assessment of study quality per AMSTAR 2.

RESULTS

All 34 included studies were observed to have at least 1 form of spin, in either the abstract or full text. The most common type of spin identified was type 5 ("The conclusion claims the beneficial effect of the experimental treatment despite a high risk of bias in primary studies"), which was observed in ten studies (10/34, 29.4%). There was a statistically significant association between studies not registered with PROSPERO and the failure to satisfy AMSTAR type 2 (P < .0001).

CONCLUSION

Misleading reporting is the most common category of spin in literature related to LDH. Spin overwhelmingly tends to go in the positive direction, with results inappropriately favoring the efficacy or safety of an experimental intervention.

The current status and development trend of hydrogel application in spinal surgery

Spinal diseases often result in compromised mobility and diminished quality of life due to the intricate anatomy surrounding the nervous system. Medication and surgical interventions remain the primary treatment methods for spinal conditions. However, currently available medications have limited efficacy in treating spinal surgical diseases and cannot achieve a complete cure. Furthermore, surgical intervention frequently results in inevitable alterations and impairments to the initial anatomical integrity of the spinal structure, accompanied by the consequential loss of certain physiological functionalities. Changes in spine surgery treatment concepts and modalities in the last decade have led to a deepening of minimally invasive treatment, with treatment strategies focusing more on repairing and reconstructing the patient's spine and preserving physiological functions. Therefore, developing novel and more efficient treatment strategies to reduce spinal lesions and iatrogenic injuries is essential. In recent years, significant advancements in biomedical research have led to the discovery that hydrogels possess excellent biocompatibility, biodegradability, and adjustable mechanical properties. The application of hydrogel-based biotechnology in spinal surgery has demonstrated remarkable therapeutic potential. This review presents the therapeutic strategies for spinal diseases based on hydrogel tissue engineering technology.

Postoperative MRI Findings Following PELD and Their Correlations with Clinical Prognosis are Investigated by Injecting Contrast into Annulus Fibrosus Intraoperatively

Objective

To validate whether a residual mass demonstrated on early postoperative MR after percutaneous endoscopic lumbar discectomy (PELD) is indeed an intraoperatively retained annulus fibrosus, and explore the correlation between imaging changes in the residual mass and clinical prognosis of patients.

Methods

A prospective study of 118 patients were included. During surgery, a contrast medium, Gadopentetate Dimeglumine, was injected around the ruptured annulus fibrosus. The intensity of the T2 signal, the size of the remaining mass (SR), and the cross-sectional area of the spinal canal (SCSA), VAS, and ODI were assessed at preoperative, 1-h (7-day), 6-month, and 12-month postoperative intervals. Based on VAS at 7 days post-surgery, patients were classified into either a non-remission group (Group A, VAS > 3) or a remission group (Group B, VAS ≤ 3).

Results

Six patients who developed recurrent LDH were excluded. A residual mass was detected on MRI 1 h after surgery in 94.6% (106/112). During one year of follow-up, 90.1% (101/112) of the patients displayed fibrous annulus remodeling, although 68.7% (77/112) still exhibited herniation. Significant differences were found in the ODI between Groups A and B one week after surgery (p < 0.001). However, no significant differences were observed in T2 signal intensity, SR, and SCSA at 1-h, 6-month and 12-month post-surgery (p > 0.05) between the two groups. In a multiple linear regression analysis, early postoperative ODI changes were associated with T2 signal (B = -10.22, sig < 0.05), long-term changes were associated with alterations in SR (B = 5.63, sig < 0.05) and SCSA (B = -0.13, sig < 0.05).

Conclusion

The residual mass observed in early postoperative MR images after PELD was the retained annulus fibrosus intraoperatively. Short-term changes in clinical symptoms after PELD were linked to T2 signal intensity, while long-term changes were associated with changes in SR and SCSA.

A study on the 10-year trend of surgeries performed for lumbar disc herniation and comparative analysis of prescribed opioid analgesics and hospitalization duration: 2010-2019 HIRA NPS Data

BACKGROUND

This study, utilizing the claims data from the Health Insurance Review and Assessment Service of Korea, aimed to examine the 10-year (2010-2019) trends in various types of lumbar spine surgeries performed on patients diagnosed with lumbar herniated intervertebral disc (HIVD), and the current status of opioid prescriptions, as well as the duration of postoperative hospital stays based on the type of surgery performed.

METHOD

This retrospective cross-sectional study examined patients with one or more national health insurance claims carrying a primary or secondary diagnosis of HIVD (ICD-10 codes: M511, M518, M519) over a 10-year period (2010-2019). From the patients undergoing lumbar spine surgery, we selected those who did not require reoperation within 30 days following the initial lumbar surgery. Our final study sample comprised patients who underwent only one type of surgery.

RESULTS

Among the patients diagnosed with HIVD and subsequently undergoing lumbar surgery between 2010 and 2019, a slight downward trend was observed in those undergoing open discectomy (OD); however, OD persistently accounted for the highest proportion over the 10 years. Percutaneous endoscopic lumbar discectomy (PELD) demonstrated a consistent upward trend from 2016 to 2018. When inspecting trends, we noted a consistent escalation over the decade in the postoperative opioid prescription rates of strong opioids (50.7% in 2010 to 77.8% in 2019) and tramadol (50.9% in 2010 to 76.8% in 2019). Analyzing these trends by surgery type, spinal fusion exhibited a slightly higher rate of opioid prescriptions than other lumbar surgeries. Regarding the length of postoperative hospital stays, patients undergoing PELD recorded the shortest stay (7.04 ± 6.78 days), while spinal fusion necessitated the longest (20.14 ± 12.18 days).

CONCLUSION

This study analyzed the trends in types of lumbar spine surgeries, opioid analgesic prescriptions, and length of hospital stays over 10 years (2010-2019) among patients with HIVD in Korea. Our data and findings provide valuable evidence that may prove beneficial for clinicians and researchers involved in HIVD-related practices.

Remove the infected interbody cage using endoscopy in lumbar spine revision surgery: A case series and technique report

BACKGROUND

Current revision surgery to remove the infected interbody cage following transforaminal lumbar interbody fusion (TLIF) surgery is challenging and traumatic. The purpose of this study is to introduce a novel surgical technique to remove the infected interbody cage for chronic infection.

METHODS

Three patients with chronic infection following TLIF surgery underwent revision surgery. Instrumentations were removed and a spinal endoscope was obliquely inserted to the disc space through the initial annular breach. Under endoscope, the cage was found, released, turned around, and dragged to the posterior edge of the disc space. The cage was then removed without distracting the dural sac and nerve roots. For two cases, appropriately sized structural iliac bone grafts were used for interbody fusion without extra instrumentations.

RESULTS

Using endoscope, the interbody cage was easy to identify and expose without disrupting the dural sac and nerve roots. With various endoscopic tools, the cage was easily released and removed. In this case series, the infected interbody cage was removed within thirty minutes without dural sac rupture and nerve root injury. The infection was controlled after the surgery, and the patients obtained good clinical outcomes. At 6-month follow-up, bony fusion was achieved in two patients who underwent interbody fusion.

CONCLUSIONS

This endoscopy assisted technique simplified the revision surgery for chronic infection followed TLIF surgery, with the advantages of no disruption of the neural tissues, bright surgical field and complete disc debridement.

Radiologic Analysis of Causes of Early Recurrence After Percutaneous Endoscopic Transforaminal Discectomy

STUDY DESIGN

Retrospective study.

OBJECTIVE

To analyze the causes of and factors influencing early recurrence after TELD performed in the treatment of lumbar disc herniation.

METHODS

We included 285 patients with single-segment lumbar disc herniation treated using transforaminal endoscopy lumbar discectomy TELD from January 2017 to December 2019 at the First Affiliated Hospital of the University of South China. Patients were classified into early recurrence and non-early recurrence groups based on clinical symptoms and MRI reexamination. Imaging data (eg, disc height index (DHI), Pfirrman grades, base width, postoperative annulus-fibrosus tear size, cross-sectional area of the foramen (CSAF), etc.)were analyzed, and multivariate, binomial logistic regression was utilized to determine which factors were associated with early recurrence after TELD.

RESULTS

A total of 285 patients completed surgery and clinical follow-up, during which 19 patients relapsed within 6 months postsurgery, for an early recurrence rate of 6.7%. There were statistically significant differences between DHI, Pfirrman grades, base width, postoperative annulus-fibrosus tear size, herniation sites, CSAF and Modic changes between the early recurrence and non-early recurrence groups (P < .05). On multivariate logistic regression,the degree of disc degeneration (OR = .747, P = .037), CSAF (OR = 5.255, P = .006), degree of Modic change (OR = 1.831, P = .018) and base width of the herniation (OR = 4.942, P = .003) were significantly correlated with early recurrence after TELD.

CONCLUSIONS

Postoperative annulus-fibrosus tear size, DHI, and location of the disc herniation were associated with early recurrence after TELD. Increased base width of the herniation, severe disc degeneration, decreased CSAF and Modic change were risk factors for early recurrence after TELD.

Comparison of percutaneous endoscopic interlaminar discectomy and conventional open lumbar discectomy for L4/5 and L5/S1 double-segmental lumbar disk herniation

OBJECTIVE

Although spinal endoscopic techniques have shown great advantages in the treatment of single-segment lumbar disk herniation (LDH), the therapeutic advantages for double-segment LDH are controversial. To compare the outcomes of percutaneous endoscopic interlaminar discectomy (PEID) versus conventional open lumbar discectomy (COLD) for the treatment of L4/5 and L5/S1 double-segmental LDH.

METHODS

From January 2016 to September 2021, we included 50 patients with double-segmental LDH who underwent PEID (n = 25) or COLD (n = 25). The clinical outcomes between the two groups were evaluated using the visual analog scale (VAS), the Oswestry disability index (ODI), and the modified MacNab criteria. Moreover, the incision length, operation time, intraoperative fluoroscopy time, postoperative bedtime, hospital stays, and complications were also recorded and compared after surgery.

RESULTS

In both groups, the VAS and ODI scores at different timepoints postoperatively were significantly improved compared with those preoperatively (P < 0.05) According to the modified MacNab criteria, the excellent or good outcome rate was 92% in the PEID group and 88% in the COLD group. The PEID group had shorter incision length, postoperative bedtime, and hospital stays than the COLD group. However, the operation time was shorter and intraoperative fluoroscopy time was fewer in the COLD group. In addition, there was no significant difference between the two groups in terms of surgical complications during the postoperative follow-up period.

CONCLUSIONS

Both PEID and COLD have good efficacy and high safety for management of L4/5 and L5/S1 double-segmental LDH. Compared with the COLD group, the PEID group had more operative time as well as more intraoperative fluoroscopy, but it had a more minimally invasive surgical incision as well as faster postoperative recovery.

A Modified Laminotomy for Interlaminar Endoscopic Lumbar Discectomy: Technical Report and Preliminary Results

OBJECTIVE

To introduce a technique of laminotomy using a common trephine to enlarge the interlaminar space at L4/5 segment for interlaminar endoscopic lumbar discectomy (IELD) and report the anatomical basis of this procedure, technical details, as well as primary clinical outcomes of a consecutive patient cohort with L4/5 lumbar disc herniation (LDH).

METHODS

On anteroposterior fluoroscopy, the intersection of the medial edge of the inferior articular process and the inferior endplate of L4 vertebra was taken as the target. Using a common trephine, laminotomy was performed to remove a big portion of the posterior wall of the canal under the guidance of endoscopy. From June 2018 to December 2021, the consecutive patients who underwent L4/5 IELD were prospectively studied. Clinical outcomes were assessed at the day before surgery, 1 day, 1 month, 3 months, 12 months after surgery, and the last follow-up. Numerical Rating Scale, Roland-Morris Disability Questionnaire (RMDQ), and MacNab criteria were used to evaluate back and leg pain, the quality of life, and clinical efficacy, respectively.

RESULTS

There were 64 men and 44 women, with an age of 50.3 ± 14.9 years. The operating time was 74.54 ± 17.42 minutes. The mean follow-up time was 32.7 ± 18.6 months (range, 12-64 months). The complications of IELD included numbness, neck pain, and recurrence. Both leg pain (6.2 ± 1.9 vs. 1.8 ± 0.8, p < 0.001) and back pain (3.1 ± 2.3 vs. 1.7 ± 0.9, p < 0.001) quickly improved after this procedure and maintained (1.1 ± 1.5, 1.1 ± 1.3) at final follow-up. Physical disability due to back pain, as assessed using RMDQ, was improved remarkably after surgery (15.0 ± 5.8 vs. 2.9 ± 4.1, p < 0.001). In addition, MacNab outcome grade was evaluated as good-to-excellent in 96 cases (88.9%).

CONCLUSION

A convenient technique of laminotomy using a common trephine was proposed for the L4/5 IELD. It can efficiently enlarge the interlaminar entry to perform endoscopic discectomy. This procedure is particularly suitable for treating LDH with concomitant lumbar spinal stenosis and migrated herniated disc.

Traditional Chinese exercises on pain and disability in middle-aged and elderly patients with lumbar disc herniation: a systematic review and meta-analysis of randomized controlled trials

Background

Traditional Chinese exercises (TCEs) have played a significant role in treating various diseases. However, there is limited research assessing the efficacy of TCEs in treating Lumbar disc herniation (LDH). This study aimed to systematically evaluate the effects of four commonly used TCEs (Baduanjin, Yijinjing, Taichi, and Wuqinxi) on pain and disability in elderly patients with LDH.

Objectives

To assess the quality of relevant randomized controlled trials (RCTs) to provide evidence support for the treatment of LDH.

Methods

RCTs were identified through eight databases. Meta-analysis and trial sequence analysis (TSA) were conducted using RevMan 5.4, Stata 17.0, and TSA 0.9.

Results

A total of 22 RCTs, involving 1931 patients, were included in the analysis. TCEs exhibited a superior effectiveness in treating LDH compared to the control group. However, the TSA analysis suggested the possibility of false positives, indicating the need for more high-quality RCT evidence. Nevertheless, TCEs showed reliable results in significantly improving the VAS score and JOA score of LDH patients.

Conclusion

Current evidence indicates that the four TCEs have advantages in treating LDH in middle-aged and elderly individuals. However, considering the limitations of this study, we need to exercise caution in drawing conclusions, and further research is required to validate these findings.

Systematic Review Registration

http://www.crd.york.ac.uk/PROSPERO, identifier [CRD42023431633].

Surgical Technique of Central and Over-the-Top Full-Endoscopic Decompression of the Cervical Spine: A Technical Note

Endoscopic surgery of the cervical spine is constantly evolving and the spectrum of its indications has expanded in recent decades. Full-endoscopic techniques have standardized the procedures for posterior and anterior access. The full-endoscopic approach was developed to treat degenerative diseases with the least possible invasion and without causing instability of the cervical spine. The posterior full-endoscopic approach is indicated for the treatment of diseases of the lateral part of the vertebral segment, such as herniations and stenoses of the lateral recess and vertebral foramen. There has been little discussion of this approach to the treatment of central stenosis of the cervical spine. This technical note describes a step-by-step surgical technique for central and over-the-top full-endoscopic decompression in the cervical spine, using a 3.7 mm working channel endoscope. This technique has already been shown to be effective in a recent case series with a 4.7 mm working channel endoscope, and may represent a new treatment option for central or bilateral lateral recess stenosis. There is also the possibility of a bilateral full-endoscopic approach, but this may be associated with greater muscle damage and a longer operative time. Case series and comparative studies should be encouraged to confirm the safety and utility of this technique.

Research Trends of Percutaneous Endoscopic Lumbar Discectomy in the Treatment of Lumbar Disc Herniation Over the Past Decade: A Bibliometric Analysis

Objective

This study aimed to explore the research trends of percutaneous endoscopic lumbar discectomy in treating lumbar disc herniation using bibliometrics over the past ten years.

Methods

Relevant publications on the clinical application of percutaneous endoscopic lumbar discectomy in lumbar disc herniation were searched in the Web of Science Core Collection. Subsequently, the characteristics of all these articles were collected. Visualizing data of annual publications, journals, cited journals, authors, cited authors, countries, institutions, keywords, and cited references was performed by using CiteSpace (6.1.R6).

Results

A total of 642 publications were extracted between 2013 and 2022. The number of publications peaked in the year 2020. The most prolific journal was World Neurosurgery (81), and Spine (597) as the cited journal was the most popular one. China (393) was the most prolific country, followed by South Korea (100). The institution with the most productivity was Tongji University (35). Yue Zhou (20) was the most prolific author, and Sebastian Ruetten (310) was the most cited author. The keyword "interlaminar" was top of research developments with the highest citation burst (8.69). "Lumbar disc herniation", "surgical technique", and "complication" were popular keywords. The surgical procedures and complications of percutaneous endoscopic lumbar discectomy have been the hot topics of recent research.

Conclusion

This study summarized the current situation and development trends of percutaneous endoscopic lumbar discectomy clinical research in the form of visualization, and these findings may help researchers explore new directions in the future.

Long-Term Radiographic and Clinical Outcomes in Patients Undergoing Transforaminal Endoscopic Lumbar Discectomy: A Propensity Score Matching Study

Background

Our study aims to investigate the long-term clinical and radiographic effects of transforaminal endoscopic lumbar discectomy (TELD) on lumbar disc herniation.

Patients and Methods

Radiographic and clinical data of patients undergoing TELD in our institution from January 2015 to January 2019 were retrospectively collected. LDH outpatients who had not received surgical treatment during the same period were 1:1 matched by propensity score matching as the conservative group. The radiographic parameters of the two groups at baseline and at the last follow-up (≥24 months) were analyzed.

Results

The study included 47 patients in the TELD group, matched with 47 patients in the conservative group. The disc height of the TELD group at the last follow-up was lower than that at the baseline (P < 0.001), and lower than that of the conservative group at the last follow-up (P < 0.05). The disc degeneration grade of the TELD group at the last follow-up was greater than that at the baseline, and greater than that of the conservative group at the last follow-up. There was no significant difference in the facet joint degeneration in the TELD group between the baseline and the last follow-up, and between the TELD group and the conservative group at the last follow-up (P > 0.05). The pain intensity and disability score in the TELD group at 3-month follow-up and at the last follow-up were significantly lower than those at the baseline (P < 0.001). Six patients in the TELD group required additional surgery during the follow-up period.

Conclusion

Our long-term follow-up data shows that the disc height of the operated level was significantly reduced and the disc degeneration was significantly aggravated in TELD-treated patients; in contrast, the facet joint degeneration did not show significant aggravation.

Biportal endoscopic discectomy versus tubular microscopic discectomy for treating single-level lumbar disc herniation in obese patients: a multicenter, retrospective analysis

PURPOSE

In microscopic lumbar discectomy in obese patients, a correlation is found between the operation time and increase in estimated blood loss according to the increase in body mass index; however, no studies have investigated the outcomes of biportal endoscopic lumbar discectomy in obese patients. Therefore, this study aimed to compare the clinical and radiographic outcomes of microscopic and endoscopic discectomy in obese patients with lumbar herniated discs.

METHODS

In this multicenter, retrospective study, clinical and radiological data were compared and analyzed in 73 obese patients with a body mass index of > 30 kg/m2 who underwent microscopic or biportal endoscopic lumbar discectomy. Clinical data on the visual analog scale (VAS), Oswestry disability index (ODI), and EuroQol-5D (EQ-5D) scores were measured, and radiological data were obtained using magnetic resonance imaging (MRI).

RESULTS

This study enrolled 43 patients who underwent microscopic discectomy and 30 who underwent biportal endoscopic discectomy. The VAS, ODI, and EQ-5D scores in both groups improved after surgery compared with those before surgery, although there was no difference between the two groups. Although there was a difference in the incidence of recurrent disc herniation confirmed by MRI after surgery, no difference was found in the number of patients requiring surgery between the two groups.

CONCLUSION

In obese patients with lumbar disc herniation that was not improved with conservative treatment, no significant clinical or radiological differences in outcomes were noted between microscopic and biportal endoscopic surgery methods. In contrast, minor complications were less common in the biportal group.

Comparative analysis of percutaneous endoscopic interlaminar discectomy for highly downward-migrated disc herniation

OBJECTIVES

This study aimed to evaluate the clinical efficacy and safety of percutaneous endoscopic interlaminar discectomy (PEID) for treating highly downward-migrated disc herniation.

METHODS

We conducted a retrospective study on 39 patients with highly downward-migrated disc herniation who underwent PEID treatment between January 2015 and October 2020. The clinical outcomes, including the preoperative and postoperative visual analogue scale (VAS) for the back and leg, Oswestry Disability Index (ODI), and MacNab criteria for surgical success, were evaluated and compared to thirty-seven patients treated with posterior lumbar interbody fusion (PLIF).

RESULTS

The mean operation time of PEID was 93.00(77.00,110.00) min, while that of PLIF was 169.00(157.00,183.00) min. Continued improvement in both PEID and PLIF was observed in the VAS and ODI scores immediately after the surgery to the last follow-up. The VAS and ODI scores of PEID one week after surgery were significantly different from those of PLIF. One patient with recurrent lumbar disc herniation in the same segment improved after undergoing repeat PEID, two patients had dura tears, and conservative treatment helped relieve the symptoms. The overall percentage of patients with good to excellent results of PELD according to the modified MacNab criteria was 97.43%, while that of PLIF was 94.60%.

CONCLUSIONS

PEID has reliable efficacy and safety for treating highly downward-migrated disc herniation. And the long-term efficacy of PEID is comparable to PLIF. No severe complications occurred after surgery, and most patients' symptoms were relieved.

Inferior Mesenteric Artery Injury in Post-lumbar Microdiscectomy: A Case Report

Iatrogenic vascular injury during lumbar microdiscectomy is a rather rare complication, but it can have fatal consequences. Here, we report a patient who underwent an L5-S1 microdiscectomy, which was complicated by inferior mesenteric artery injury. The patient presented in the recovery room with symptoms of hypotension and tachycardia after the operation which was successfully managed by endovascular embolization. The patient was positioned in a prone position, which may have contributed to the development of vascular injury. To prevent potential complications, we advised using the Jackson table rather than a standard surgical table and thoroughly inspecting the abdomen and pelvis prior to the operation.

S1 Transforaminal Epidural Anesthesia in Percutaneous Transforaminal Endoscopic Discectomy: A Case-Series Study

Background

Percutaneous transforaminal endoscopic discectomy (PTED) has become popular over the years due to its safety and low invasiveness. This surgery can be performed with different anesthesia techniques; however, the extent to which the surgeon and patient are satisfied with the analgesia is debatable.

Objectives

This study investigated the efficiency of the S1 transforaminal epidural block.

Methods

This retrospective study was conducted on 60 patients with L4 - L5 lumbar disc herniation who underwent PTED under the S1 transforaminal epidural block. All patients had clinical symptoms associated with unilateral radiculopathy and were candidates for surgery. Percutaneous transforaminal endoscopy and S1 epidural block were performed by a surgeon for all patients.

Results

Of the 60 evaluated cases, 61.7% and 38.3% were female and male, respectively, with a mean age of 42.98 ± 10.79 years. The mean pain score before surgery was 7.83 ± 0.69, which decreased to 2.58 ± 0.65 during surgery and 0.50 ± 0.50 48 hours after surgery (P < 0.001). The mean duration of operation in these patients was 58.58 ± 16.95 minutes, and the mean onset time was 10.08 ± 3.12 minutes. Moreover, the mean bleeding was 124.17 ± 25.20 cc.

Conclusions

The PTED with S1 epidural anesthesia is a simple, safe, and effective method that causes good analgesia during the operation and cooperates well with the surgeon in neurological monitoring due to patient consciousness.

Uniportal versus biportal endoscopic spine surgery: a comprehensive review

INTRODUCTION

Endoscopic spine surgery techniques are minimally invasive alternatives to conventional open surgery for degenerative spinal diseases. Clinical studies and meta-analyses have proven the usefulness of uniportal full-endoscopic spine procedures. However, a steep learning curve is a critical barrier for endoscopic procedures. Recently, biportal endoscopic spine surgeries have been developed to make it easier for spine surgeons to learn and perform. Consequently, the biportal approach has gained popularity among aspiring endoscopic spine surgeons. This review compared the characteristics of uniportal and biportal surgeries to help spine surgeons perform endoscopic procedures more effectively.

AREA COVERED

The review analyzed English-language clinical literature in Core databases and compared uniportal and biportal endoscopic spine surgery techniques. Clinical studies have compared the technical principles of both techniques, and the authors suggested appropriate strategies for learning and practicing endoscopic procedures.

EXPERT OPINION

Uniportal, full-endoscopic spine surgery is a minimally invasive procedure that preserves muscles and uses a keyhole approach under local anesthesia. In contrast, biportal surgery is more familiar to a surgeon and can be performed more widely, although the keyhole approach is limited. Aspiring endoscopic spine surgeons can learn either method according to the surgeon's preference and the clinical situation.

Background, techniques, applications, current trends, and future directions of minimally invasive endoscopic spine surgery: A review of literature

Across many of the surgical specialties, the use of minimally invasive techniques that utilize indirect visualization has been increasingly replacing traditional techniques which utilize direct visualization. Arthroscopic surgery of the appendicular skeleton has evolved dramatically and become an integral part of musculoskeletal surgery over the last several decades, allowing surgeons to achieve similar or better outcomes, while reducing cost and recovery time. However, to date, the axial skeleton, with its close proximity to critical neural and vascular structures, has not adopted endoscopic techniques at as rapid of a rate. Over the past decade, increased patient demand for less invasive spine surgery combined with surgeon desire to meet these demands has driven significant evolution and innovation in endoscopic spine surgery. In addition, there has been an enormous advancement in technologies that assist in navigation and automation that help surgeons circumvent limitations of direct visualization inherent to less invasive techniques. There are currently a multitude of endoscopic techniques and approaches that can be utilized in the treatment of spine disorders, many of which are evolving rapidly. Here we present a review of the field of endoscopic spine surgery, including the background, techniques, applications, current trends, and future directions, to help providers gain a better understanding of this growing modality in spine surgery.

Implementation of a Canine Ergonomic Abdominal Simulator for Training Basic Laparoscopic Skills in Veterinarians

The validity of the CALMA Veterinary Lap-trainer simulator (CVLTS) for training basic veterinary laparoscopic skills was assessed and compared to a simple collapsible mobile box trainer. Ten veterinarian surgeons with no experience in laparoscopic surgery and four experts with at least two years of experience in minimally invasive surgery (MIS) were included. The training curriculum included object transfer, non-woven gauze cutting with curved scissors, and interrupted and continuous intracorporeal sutures, which were practiced on the CVLTS. The initial and final assessments were carried out in both the CVLTS and in a collapsible mobile simulator. These were video-recorded and evaluated by external experts using the Objective Structured Assessment of Technical Skills (OSATS) and a specific scale evaluation in a double-blinded schedule. The time, angular displacement, number, and movement smoothness were recorded using a hands movement assessment system (HMAS). Through a survey, the face validity and content were evaluated. The data were analyzed by a Pearson's proportions comparison or Mann Whitney U test and a bilateral Student's t-test. The experimental group OSATS, specific scores, and HMAS values, with the exception of the smoothness of movements, significantly improved after training, with no statistically significant differences compared to the expert group. No differences were found between the two simulators. The experts' and experimental participants' CVLTS mean score was 4.8. Our data support the CVLTS validations for laparoscopic surgery basic skills training.

Effects of the administration of Shinbaro 2 in a rat lumbar disk herniation model

The current standard for the pharmacological management of lumbar disk herniation (LDH), involving non-steroidal anti-inflammatory drugs, muscle relaxants, and opioid analgesics, often carries a risk of adverse events. The search for alternative therapeutic options remains a vital objective, given the high prevalence of LDH and the critical impact on the quality of life. Shinbaro 2 is a clinically effective herbal acupuncture against inflammation and various musculoskeletal disorders. Therefore, we explored whether Shinbaro 2 exerts protective effects in an LDH rat model. The results showed that Shinbaro 2 suppressed pro-inflammatory cytokines, interleukin-1 beta, tumor necrosis factor-alpha, disk degeneration-related factors, matrix metalloproteinase-1,−3,−9, and ADAMTS-5 in LDH rats. Shinbaro 2 administration reinstated a behavioral activity to a normal level in the windmill test. The results indicated that Shinbaro 2 administration restored spinal cord morphology and functions in the LDH model. Therefore, Shinbaro 2 exerted a protective effect in LDH via actions on inflammatory responses and disk degeneration, indicating that future research is warranted to assess the action mechanisms further and validate its effects.

Percutaneous Transforaminal Endoscopic Surgery (PTES) for Treatment of Lumbar Degenerative Disease in Patients with Underlying Diseases: A Retrospective Cohort Study of 196 Cases

Objective

To evaluate the postoperative outcomes, safety and feasibility of percutaneous transforaminal endoscopic surgery (PTES) for the treatment of lumbar degenerative disease (LDD) in the patients with underlying diseases.

Methods

From June 2017 to April 2019, PTES was performed to treat 226 patients of single-level LDD. According to clinical background, the patients were divided into two groups. A total of 102 patients with underlying diseases were included in group A. The other 124 LDD patients without underlying diseases were included in group B. The occurrence of postoperative complications was recorded. Leg pain was assessed before, immediately, 1 month, 2 months, 3 months, 6 months, 1 year, and 2 years after PTES using VAS, and ODI before PTES and 2 years after PTES were recorded. The therapeutic quality (Excellent, Good, Moderate or Poor) was defined according to MacNab grade at 2-year follow-up.

Results

No aggravation of underlying diseases or serious complications was observed in all patients within 6 months after the operation. Altogether, 196 patients were followed up for more than 2 years, 89 patients in group A and 107 patients in group B. The VAS score of leg pain and ODI dropped significantly after surgery (P<0.001) in both groups. One case of group B received PTES again due to recurrence 52 months after surgery. According to MacNab, the excellent and good rate was 97.75% (87/89) in group A and 96.26% (103/107) in group B. In operative duration, frequency of intraoperative fluoroscopy, blood loss, incision length, hospital stay, VAS, ODI, and the excellent and good rate, there was no statistical difference between the two groups.

Conclusion

PTES is safe, effective and feasible for the treatment of LDD with underlying diseases, which is comparable to PTES for LDD without underlying diseases. The entrance point of PTES (Gu's Point) is located at the corner of the flat back turning to the lateral side. PTES is not only a minimally invasive surgical technique but also includes a postoperative care system for preventing LDD recurrence.

Global research productivity in the field of discectomy on lumbar disc herniation: A systematic bibliometric analysis

Objective

To evaluate the global research productivity in the field of discectomy for lumbar disc herniation (LDH) through bibliometric analysis and mapping knowledge domains.

Methods

A systematic literature search was performed on the Web of Science (WoS), including the Science Citation Index Expanded (SCIE) database and PubMed. The number of publications, countries of publications, journals of publications, total citation frequency, impact factors of journals, and Institutional sources were analyzed by Microsoft Excel 2019, the Online Analysis Platform of Bibliometrics, and VOSviewer. Hotspots were also analyzed and visualized based on VOSviewer.

Results

A total of 2,066 papers were identified. The United States ranked first in the number of total citations (7,970). China ranked first in the number of publications (556, 26.9%), which has surpassed the United States in terms of the number of publications published annually since 2016. Wooridul Spine Hospital published the most papers (43). For journals, Spine has published the largest number of papers (289) in this field with the most citation frequencies (6,607). Hotspots could be divided into three clusters: surgery, lumbar disc herniation, and diagnoses. The most recent topic that appeared was symptomatic re-herniation.

Conclusions

The United States is the most significant contributor to the development of discectomy for LDH. The current research focus of discectomy on LDH was the comparison between surgical approaches and evaluation of current minimally invasive discectomy. At present, minimally invasive techniques, such as endoscopic discectomy, cannot completely replace non-endoscopic discectomy (open discectomy and microdiscectomy) through bibliometric analysis and mapping knowledge domains.

Optimal approach for total endoscopic discectomy and its effect on lumbar and leg function in patients with disc herniation

BACKGROUND

Disc herniation (DH) is a fragment of the disc nucleus that is pushed out of the annulus into the spinal canal due to a tear or rupture in the annulus. It is a common cause of lumbar and leg pains. Substantial advancements have been made to determine the cause of DH and to ensure accurate diagnosis, imaging, and treatment of this condition. Total endoscopic discectomy is an alternative surgical technique that is less invasive.

AIM

To study the optimal approach for a total endoscopic discectomy and its influence on lumbar and leg function in DH patients.

METHODS

This prospective study enrolled 120 patients with lumbar DH who were treated in our hospital from February 2018 to January 2021. All patients were randomly divided into the following two groups: The observation group, comprising 62 patients who underwent surgery using the interlaminar approach, and the control group, comprising 58 patients who were operated through the foramina approach. The treatment effects, perioperative indicators, functional recovery, pain, and quality of life were compared between the two groups.

RESULTS

The treatment effect in the observation group (93.55%) was significantly better than that in the control group (77.59%). There was no difference in the operative time and intraoperative blood loss amount between the two groups (P > 0.05). The hospitalization time of the observation group (4.34 ± 1.33 d) was significantly shorter than that of the control group (5.38 ± 1.57 days) (P < 0.05). The Japanese Orthopaedic Association and Oswestry Disability Index scores decreased significantly in both groups after treatment, but the scores were lower in the observation group than in the control group. The visual analog scale scores of the lower back and legs of the two groups were significantly reduced after treatment, but scores were lower in the observation group (2.18 ± 0.88 in the lower back and 1.42 ± 0.50 in the leg) than in the control group (3.53 ± 0.50 in the lower back and 2.21 ± 0.52 in the leg). A short form of the Arthritis Impact Measurement Scales 2 measurement scale (AIMS2-SF) score and Barthel index of the lower back of the two groups increased significantly after treatment, with the observation group having a significantly higher AIMS2-SF score (95.16 ± 1.74) and Barthel index (97.29 ± 1.75) than the control group (84.95 ± 2.14 and 89.16 ± 2.71, respectively) (P < 0.05).

CONCLUSION

Through total endoscopic discectomy with the interlaminar approach, the degree of pain in the waist and leg was reduced, and the lumbar function considerably recovered.

The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain

Introduction

Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety.

Objective

The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders.

Methods

The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented.

Results

After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain.

Conclusion

The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.

[Comparison of effectiveness of unilateral biportal endoscopy technique and the interlaminar uniportal endoscop technique for treatment of L 5, S 1 lumbar disc herniation]

Objective

To compare the effectiveness of unilateral biportal endoscopy (UBE) technique with the interlaminar uniportal endoscopy (IUE) technique for the treatment of L 5, S 1 lumbar disc herniation.

Methods

The clinical data of 69 patients with L 5, S 1 lumbar disc herniation who met the selection criteria between January 2020 and December 2020 were retrospectively analysed. The patients were divided into UBE group (30 cases) and IUE group (39 cases) according to endoscopic surgical technique. The general data, such as gender, age, body mass index, disease duration, and preoperative visual analogue scale (VAS) scores of low back/leg pain and Oswestry disability index (ODI), was not significantly different between the two groups ( P>0.05). Perioperative outcomes [estimated blood loss (EBL), total operation time, extracanal operation time, intracanal decompression time, intraoperative radiation exposure dose, incision length, operative related complications, and postoperative hospitalization stay] and clinical outcomes (VAS score of low back/leg pain before operation and at 3 days, 3 months, 6 months, and 12 months after operation as well as the ODI before operation and at 3 months, 6 months, and 12 months after operation) were recorded and compared between the two groups.

Results

All patients completed the surgery successfully. The incision length, EBL, and extracanal operation time in UBE group were significantly longer than those in IUE group ( P<0.05), and the intracanal decompression time in UBE group was significantly shorter than that in IUE group ( P<0.05). There was no significant difference in the total operation time, intraoperative radiation exposure dose, and postoperative hospitalization stay between the two groups ( P>0.05). Patients in both groups were followed up 12-15 months (mean, 13.3 months). Dural tear ocurred in 1 patient of the UBE group, and recurrence ocurred in 1 patient of the IUE group, the others of both groups had no surgery-related complications and recovered well after operation. The VAS scores of low back/leg pain and ODI in both groups at each time point after operation significantly improved when compared with those before operation ( P<0.05); there was no significant difference in VAS scores and ODI at each time point after operation between two groups ( P>0.05).

Conclusion

The effectiveness of UBE technique in the treatment of L 5, S 1 lumbar disc herniation is similar to that of IUE technique, and the efficiency of intraspinal operation is better than that of IUE technique. Although UBE technique is inferior to IUE technique in terms of surgical trauma, there is no significant difference in postoperative recovery between the two techniques.

MRI changes of adjacent segments after transforaminal lumbar interbody fusion (TLIF) and foraminal endoscopy: A case-control study

BACKGROUND

Intervertebral foramen endoscopy has developed rapidly, but compared with transforaminal lumbar interbody fusion (TLIF), the progress of degeneration is unknown. We aim to compare the changes of intervertebral disc and intervertebral foramen in adjacent segments after TLIF and endoscopic discectomy for patients with lumbar disc herniation (LDH).

METHODS

From 2014 to 2017, 87 patients who were diagnosed with single-level LDH and received surgery of TLIF (group T, n = 43) or endoscopic discectomy (group F, n = 44) were retrospectively analyzed. X-ray, MRI, CT and clinical symptoms were recorded before operation and at the last follow-up (FU). The neurological function was originally evaluated by the Japanese Orthopaedic Association (JOA) scores. Radiological evaluation included the height of intervertebral space (HIS), intervertebral foramen height (FH), intervertebral foramen area (FA), lumbar lordosis (CA) and intervertebral disc degeneration Pfirrmann scores.

RESULTS

There was no significant difference in baseline characteristics, JOA improvement rate, reoperation rate and complications between the two groups. The age, average blood loss, average hospital stays and average operation time in group F were lower than those in group T. During the last FU, HIS, CA and FA decreased in both groups, and the changes in group T were more significant than those in group F (P < .05). There was no significant difference in FH changes between the two groups (P > .05).

CONCLUSION

Both TLIF and endoscopic surgery can achieve good results in the treatment of LDH, but the risk of lumbar disc height loss and intervertebral foramina reduction in the adjacent segment after endoscopic surgery is lower.

The clinical efficacy of biportal endoscopy is comparable to that of uniportal endoscopy via the interlaminar approach for the treatment of L5/S1 lumbar disc herniation

Objective

To compare the clinical outcomes of unilateral biportal endoscopy/biportal endoscopic spinal surgery (UBE/BESS) via the posterior approach with those of interlaminar endoscopic lumbar discectomy (IELD) for the treatment of L5/S1 lumbar disc herniation.

Methods

We collected the clinical data of patients with L5/S1 lumbar disc herniation who had undergone endoscopic surgery at our center from January 2020 to July 2021, and 92 patients were included. They were divided into UBE/BESS (n = 42) and IELD (n = 50) groups. The incision length, operative time (overall operative, extracanal operative, and intracanal decompression times), intraoperative radiation exposure dose, changes in hemoglobin before and after surgery, postoperative hospital stay, visual analog scale (VAS) score for low back pain and leg, and Oswestry disability index (ODI) were statistically analyzed.

Results

One case incurred dural tear in the UBE/BESS group, and one case developed recurrence in the IELD group. Postoperatively, the VAS score and ODI index decreased significantly in both groups (P < 0.01). VAS and ODI scores (preoperative as well as 3 days, 3 months, 6 months, and 12 months after surgery), the overall operative time, and postoperative hospital stay were not significantly different between the two groups (P > 0.05). No statistical difference in intraoperative radiation exposure dose was noted between the two groups (P > 0.05). The surgical incision length was greater in the UBE/BESS group (P < 0.01), and pre- and postoperative hemoglobin changes were more pronounced in the UBE/BESS group (P < 0.01). The UBE/BESS group had a longer extracanal operative time and shorter intracanal decompression time (P < 0.01).

Conclusions

The clinical efficacy of UBE/BESS for L5/S1 lumbar disc herniation is comparable to that of IELD. Intraoperative radiation exposure doses were similar in both techniques. UBE/BESS required more time to identify tissue structures and a larger working space when operating outside the spinal canal; however, the efficiency of nucleus pulposus removal and nerve root release inside the spinal canal superseded that in IELD. Furthermore, the surgical incision in the UBE/BESS technique was longer, with greater actual blood loss during surgery, thus rendering UBE/BESS inferior to the IELD technique in terms of surgical trauma. Nonetheless, no significant difference was noted between the two techniques in the postoperative recovery time of patients.

Risk Factors Involved in the Early and Medium-Term Poor Outcomes of Percutaneous Endoscopic Transforaminal Discectomy: A Single-Center Experience

Objective

To investigate the risk factors involved in the early and medium-term poor outcomes of percutaneous endoscopic transforaminal discectomy (PETD) treatment of lumbar disc herniation (LDH) at the L4-5 level.

Methods

Between January 2015 and May 2020, we recruited 148 LDH patients at the L4-5 level who underwent PETD surgery. The patients were divided into Groups A and B, according to the surgical outcomes. Good and excellent outcomes were categorized into Group A, and generally good and poor outcomes were categorized into Group B. Clinical parameters (age, gender, symptom duration, hospital stay, operation time, blood loss, straight-leg raising (SLR), visual analog scale (VAS), Oswestry Disability Index (ODI) score and modified MacNab criteria) and radiologic parameters (foraminal height (FH), intervertebral height index (IHI), intervertebral angle (IVA), sagittal range of motion (sROM), and lumbar lordosis (LL)) were collected and analyzed using univariate and multiple logistic regression analyses.

Results

At the 6-month follow-up post operation, univariate analysis revealed that the symptom duration, SLR, IHI, and sROM were strongly associated with poor outcomes. However, multiple logistic regression analysis demonstrated that prolonged symptom duration, large SLR angel, and large sROM were independent risk factors for poor outcomes. At the 2-year follow-up post operation, univariate analysis suggested that advanced age, prolonged symptom duration, large preoperative VAS score, small FH, small IHI, and large sROM were potential risk factors for poor outcomes. However, multiple logistic regression analysis demonstrated that prolonged symptom duration, small IHI, and large sROM were independent risk factors for poor outcomes.

Conclusion

Our study demonstrated that prolonged symptom duration, large SLR angel, and large sROM were independent risk factors for poor outcomes immediately following PETD at the L4-5 level. However, prolonged symptom duration, small IHI, and large sROM were independent risk factors for poor outcomes at medium-term post PETD at the L4-5 level.

Citation analysis of the 100 top-cited articles on discectomy via endoscopy since 2011 using alluvial diagrams: bibliometric analysis

Background

Percutaneous endoscopic lumbar discectomy (PELD) is synonymous with percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID). PEID has gained increasing recognition for its small incision, quick recovery, short hospital stay, and equivalent clinical outcome to open surgery. Numerous articles related to PEID have been published in the literature. However, which countries, journals, subject categories, and articles have ultimate influence remains unknown. The study aimed to (1) display influential entities in 100 top-cited PEID-related articles (T100PEID) on the alluvial diagram and (2) investigate whether medical subject headings (i.e., MeSH terms) can be used to predict article citations.

Methods

T100PEID data can be found since 2011 in the PubMed and Web of Science (WOS) databases. Using alluvial diagrams, citation analysis was conducted to compare the dominant entities. We used social network analysis (SNA) to classify MeSH terms and research areas extracted from PubMed and WOS. The difference in article citations across subject categories and the predictive power of MeSH terms on article citations in T100 PEID were examined using one-way analysis of variance (ANOVA) and regression analysis.

Results

A total of 81% of T100PEID is occupied by the top three countries (the US, China, and South Korea). There was an overall T100PEID impact factor of 41.3 (IF = citations/100). Articles were published in Spine (Phila Pa 1976) (23%; IF = 41.3). Six subject categories were classified using the SNA. The most cited article authored by D Scott Kreiner from Ahwatukee Sports and Spine in the US state of Phoenix had 123 citations in PubMed. The network characteristics of T100PEID are displayed on the alluvial diagram. No difference was found in article citations among subject categories (F = 0.813, p = 0.543). The most frequently occurring MeSH term was surgery. MeSH terms were evident in the prediction power of the number of article citations (F = 15.21; p < 0 .001).

Conclusion

We achieved a breakthrough by displaying the T100PEID network characteristics on the alluvial plateau. The MeSH terms can be used to classify article subject categories and predict T100PEID citations. The alluvial diagram can be applied to bibliometrics on 100 top-cited articles in future studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40001-022-00782-0.

An Alluvial diagram was drawn to display the network characteristics of T100PEID, which is novel and modern in the literature.

The method of drawing the Alluvial demonstrated in detail with documents in supplemental digital contents can be applied to make bibliometric studies brief, concise, and powerful.

The impact beam plot (IBP) is an additional visualization introduced in this study. The online IBP was demonstrated and worthy of future similar studies to highlight the most influential articles with a glance at a picture.

Intradiscal oxygen-ozone chemonucleolysis versus microdiscectomy for lumbar disc herniation radiculopathy: a non-inferiority randomized control trial

BACKGROUND CONTEXT

Low back pain with or without radicular leg pain is an extremely common health condition significantly impacting patient's activities and quality of life. When conservative management fails, epidural injections providing only temporary relief, are frequently utilized. Intradiscal oxygen-ozone may offer an alternative to epidural injections and further reduce the need for microdiscectomy.

PURPOSE

To compare the non-inferiority treatment status and clinical outcomes of intradiscal oxygen-ozone with microdiscectomy in patients with refractory radicular leg pain due to single-level contained lumbar disc herniations.

STUDY DESIGN / SETTING

Multicenter pilot prospective non-inferiority blocked randomized control trial conducted in three European hospital spine centers.

PATIENT SAMPLE

Forty-nine patients (mean 40 years of age, 17 females/32 males) with a single-level contained lumbar disc herniation, radicular leg pain for more than six weeks, and resistant to medical management were randomized, 25 to intradiscal oxygen-ozone and 24 to microdiscectomy. 88% (43 of 49) received their assigned treatment and constituted the AS-Treated (AT) population.

OUTCOME MEASURES

Primary outcome was overall 6-month improvement over baseline in leg pain. Other validated clinical outcomes, including back numerical rating pain scores (NRS), Roland Morris Disability Index (RMDI) and EQ-5D, were collected at baseline, 1 week, 1-, 3-, and 6-months. Procedural technical outcomes were recorded and adverse events were evaluated at all follow-up intervals.

METHODS

Oxygen-ozone treatment performed as outpatient day surgeries, included a one-time intradiscal injection delivered at a concentration of 35±3 μg/cc of oxygen-ozone by a calibrated delivery system. Discectomies performed as open microdiscectomy inpatient surgeries, were without spinal instrumentation, and not as subtotal microdiscectomies. Primary analyses with a non-inferiority margin of -1.94-point difference in 6-month cumulative weighted mean leg pain NRS scores were conducted using As-Treated (AT) and Intent-to-Treat (ITT) populations. In post hoc analyses, differences between treatment groups in improvement over baseline were compared at each follow-up visit, using baseline leg pain as a covariate.

RESULTS

In the primary analysis, the overall 6-month difference between treatment groups in leg pain improvement using the AT population was -0.31 (SE, 0.84) points in favor of microdiscectomy and using the ITT population, the difference was 0.32 (SE, 0.88) points in favor of oxygen-ozone. The difference between oxygen-ozone and microdiscectomy did not exceed the non-inferiority 95% confidence lower limit of treatment difference in either the AT (95% lower limit, -1.72) or ITT (95% lower limit, -1.13) populations. Both treatments resulted in rapid and statistically significant improvements over baseline in leg pain, back pain, RMDI, and EQ-5D that persisted in follow-up. Between group differences were not significant for any outcomes. During 6-month follow-up, 71% (17 of 24) of patients receiving oxygen-ozone, avoided microdiscectomy. The mean procedure time for oxygen-ozone was significantly faster than microdiscectomy by 58 minutes (p<.0010) and the mean discharge time from procedure was significantly shorter for the oxygen-ozone procedure (4.3±2.9 hours vs. 44.2±29.9 hours, p<.001). No major adverse events occurred in either treatment group.

CONCLUSIONS

Intradiscal oxygen-ozone chemonucleolysis for single-level lumbar disc herniations unresponsive to medical management, met the non-inferiority criteria to microdiscectomy on 6-month mean leg pain improvement. Both treatment groups achieved similar rapid significant clinical improvements that persisted and overall, 71% undergoing intradiscal oxygen-ozone were able to avoid surgery.

Comparison of Endoscopic Discectomy Versus Non-Endoscopic Discectomy for Symptomatic Lumbar Disc Herniation: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review.

OBJECTIVE

The authors aimed to systematically compare the effectiveness and safety of endoscopic discectomy (ED) with non-endoscopic discectomy (NED) for treatment of symptomatic lumbar disc herniation (LDH).

METHODS

A systematic search was performed on PubMed, EMBASE, the Cochrane Library and China National Knowledge Infrastructure for randomized controlled trial from inception until August 13, 2020. Trials which investigated multiple operative approaches on lumbar disc herniation were identified without language restrictions.

RESULTS

In total, 25 trials involving 2258 patients with symptomatic LDH were included. Twenty trials performed the comparison between ED and NED. Five trials performed the comparison between percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID). The operative time of micro-endoscopic discectomy (MED) was longer than open discectomy (OD). The length of hospital stay of percutaneous endoscopic lumbar discectomy (PELD) was shorter than fenestration discectomy (FD). Significant differences in intraoperative blood loss volumes were found between PELD with FD and MED with OD. The complication rate of PELD was lower than FD (PELD: 4.3%; FD: 14.6%) and the complication rate of full-endoscopic discectomy (FE) was lower than microscopic discectomy (MD) (FE: 13.4%; MD: 32.1%).

CONCLUSIONS

PELD and FE have the advantage of limiting intraoperative damages. ED and NED can be both considered sufficient to achieve good clinical outcomes. PETD and PEID are able to achieve similar results but the learning curve of PETD was steeper. More independent high-quality RCTs with sufficiently large sample sizes performing cost-effectiveness analyzes are needed.

Is minimally invasive orthopedic surgery safer than open? A systematic review of systematic reviews

BACKGROUND

To assess the safety of minimally invasive surgery (MIS) for orthopedic spinal, upper limb and lower limb procedures, this systematic review of systematic reviews compared their complications with open procedures.

MATERIALS AND METHODS

A literature search was conducted electronically (PubMed, Cochrane library and Web of Science; May 8, 2021) without language restriction in the past five years. Reviews that consulted at least two databases, compared MIS with open orthopedic surgery, and reported the following: intraoperative, post-operative or total complications, function, ambulation, pain, hospital stay, reoperation rate and operation time were included. Article selection, quality assessment using AMSTAR-2, and data extraction were conducted in duplicate on predesigned forms. In each review, a subset analysis focusing on prospective cohort and randomized studies was additionally performed.

PROSPERO

CRD42020178171.

RESULTS

The search yielded 531 articles from which 76 reviews consisting of 1104 primary studies were included. All reviews were assessed as being low quality. Compared to open surgery, MIS had fewer total, postoperative and intraoperative complications in 2/10, 2/11 and 2/5 reviews of spinal procedures respectively, 1/3, 1/4 and 1/2 reviews of upper limb procedures respectively, and 4/6, 2/7 and 0/2 reviews of lower limb procedures respectively.

CONCLUSIONS

MIS had greater overall safety compared to open surgery in spinal procedures. In upper limb and lower limb procedures, MIS was not outright superior to open procedures in terms of safety hence a general preference of MIS is not justified on the premise of a better safety profile compared to open procedures.

Percutaneous Endoscopic Lumbar Discectomy for Lumbar Disc Herniation With Type II Modic Changes

BACKGROUND

Percutaneous endoscopic lumbar discectomy (PELD) has become a favorable surgical approach for lumbar radiculopathy caused by intervertebral disc herniation. Studies have revealed patients with type II Modic change may suffer from unrelieved low back pain and higher lumbar disc herniation (LDH) recurrence after herniated nucleus pulposus removal. Therefore, in this study, we aim to evaluate how PELD performed in management of LDH patients with type II Modic change.

METHODS

We collected 267 single-level LDH cases aged 20-50 yearswho underwent PELD from December 2016 to December 2019. The mean follow-up time was 26.3 months (range: 12-48 months). The visual analog scale (VAS), Oswestry Disability Index (ODI), and MacNab scores, as well as the recurrence rate, were analyzed pre- and post-surgery, as well as at the time points of 3 months, 12 months, and the final follow-up time after surgery. The clinical outcomes in LDH patients with or without type II Modic change who underwent PELD were thoroughly analyzed.

RESULTS

Within the 267 LDH patients enrolled, 145 cases present Modic signals, among which 3 are type I and 142 are type II. The VAS and ODI scores of the patients in the 2 groups at different follow-up times were significantly lower than those before surgery. The excellent and good MacNab scores in the control group and Modic type II change group were 87.0% and 82.1%, respectively. However, with the extension of follow-up time, the VAS and ODI scores, as well as the recurrence rate, were found to be higher in the type II Modic change group when compared with those in the non-Modic change group.

CONCLUSIONS

PELD performed well in management of LDH patients. However, we need to pay more attention to the continuous low back pain and the recurrence possibility in the cases with type II Modic change. In these cases, longer brace support or other interventions could be applied.

Transforaminal Endoscopic Discectomy Under General and Local Anesthesia: A Single-Center Study

Percutaneous spinal endoscopy is used for the treatment of disorders of the lumbar spine, as it has several advantages over traditional surgical methods. The performance of percutaneous spinal endoscopy is not possible without applying anesthesia methods. Two types (local and general) of anesthesia are used for percutaneous spinal endoscopy. Both, local and general anesthesia approaches contribute to safety in surgical procedures. Although it is believed that the method of local anesthesia has more benefits over general anesthesia, such as lowering the risk of postoperative neurological complications in a patient, the literature on the topic is inconclusive. The study aims to perform a comparative analysis of the two anesthesia methods using a prospective case-control design. Patients were divided into two groups: those who received local anesthesia (LA) (20 patients), and those who underwent general anesthesia (GA) (20 patients). As a result of the study, 40% of the patients experienced moderate pain and 5% of the patients experienced excruciating pain intraoperatively in the LA group. Although Visual Analog Scale and Oswestry Disability Index scores improved more rapidly in LA group, at the 12-month check-up point there was no significant difference between cases and controls. Nevertheless, there were postoperative complications such as nerve root injury in 10% of the patients; nausea, vomiting, dizziness, drowsiness in 15% of the patients in the GA group, and an insignificant or no such complications in patients of the LA group. The present study demonstrates that LA contributes to more positive short-term outcomes for patients as it facilitates nerve root damage prevention, and has no postoperative side effects on patients' well being.

Comparative study of the efficacy and safety of minimally invasive interlaminar full-endoscopic discectomy versus conventional microscopic discectomy in single-level lumbar herniated intervertebral disc (ENDO-F Trial): a multicenter, prospective, randomized controlled trial protocol

Background

Advances in minimally invasive surgery have expanded the indications for interlaminar full-endoscopic discectomy. Although the clinical outcomes for this approach may be equivalent to those of conventional microscopic discectomy, the supporting evidence is still based on small, single-center, prospective, and retrospective studies. Therefore, a multicenter randomized controlled trial is warranted.

Methods

This will be a prospective, multicenter, randomized controlled trial comparing the efficacy and safety of interlaminar full-endoscopic discectomy to those of conventional microscopic discectomy. The trial will enroll 100 participants with a lumbar disc herniation, 50 in each group. The primary outcome will be the Oswestry Disability Index (ODI) score at 12 months post-surgery. Secondary outcomes will be back and leg pain (visual analog scale); the ODI; the EuroQol-5-dimension score; patient satisfaction; and walking distance/time and time to return to daily activities post-surgery. Surgical outcomes will include postoperative drainage, operative time, duration of hospital stay, postoperative creatine kinase level as an indicator of muscle injury, and postoperative scarring. Postoperative magnetic resonance imaging, computed tomography, and simple radiography will be performed to evaluate radiographic outcomes between the two surgical approaches. Surgery-related complications and adverse effects will be evaluated as safety outcomes. A single assessor at each participating hospital, blinded to group allocation, will assess the enrolled participants at baseline, at 2 weeks, and at 3, 6, and 12 months postoperatively.

Discussion

This trial is designed to determine whether interlaminar full-endoscopic discectomy is clinically comparable to microscopic discectomy to treat lumbar disc herniations. All efforts will be made to reduce bias, including adequate sample size, blinded analyses, and multicenter prospective registration. The outcomes will inform practice, providing the evidence needed for using interlaminar full-endoscopic over microscopic discectomy by confirming the potential of this technique to improve patient satisfaction and clinical outcomes.

Trial registration: Clinical Research Information Service; cris.nih.go.kr. (KCT0006277); protocol version (v1, June 8, 2021).

A New Grading System for Migrated Lumbar Disc Herniation on Sagittal Magnetic Resonance Imaging: An Agreement Study

Understanding the degree of disc migration is essential in order to diagnose, treat, and assess the prognosis of migrated lumbar disc herniation (LDH). Based on anatomical configuration, we developed a simple six-level grading system for migrated lumbar disc herniation. We aimed to evaluate whether the new grading system was reliable and could replace the previous grading system. We selected 101 cases from our database. Two independent raters evaluated the magnetic resonance images using each grading system. Interobserver, intraobserver, and inter-grading system agreements were assessed using kappa statistics. The most common migration pattern was low-grade inferior migration. Interobserver agreements between the two readers showed substantial agreement in the first and second assessments (k = 0.753 and 0.756, respectively). The intraobserver agreement of reader 1 revealed substantial agreement (k = 0.733), while that of reader 2 revealed almost perfect agreement (k = 0.829). The strengths of the agreements of the new grading system were higher than those of the Lee-Kim grading system. The two grading systems agreed almost perfectly for most measurements. The new grading system was reliable and feasible to determine migrated LDH grade. It allowed for a more intuitive, objective measurement and helped select surgical options.