Different approaches to percutaneous endoscopic lumbar discectomy for L5/S1 lumbar disc herniation: a retrospective study

Comparison of Full Endoscopic Lumbar Diskectomy Using the Transforaminal Approach versus Interlaminar Approach for L5-S1 Lumbar Disk Herniation Treatment: A Meta-Analysis

BACKGROUND

 Numerous studies have examined the clinical effectiveness of transforaminal full endoscopic lumbar diskectomy (T-FELD) and interlaminar full endoscopic lumbar diskectomy (I-FELD) for L5-S1 lumbar disk herniation (LDH), with mixed findings. The goal of this systematic review and meta-analysis was to evaluate the perioperative outcomes, clinical results, and complications of T-FELD and I-FELD to determine their efficacy and safety for treating L5-S1 LDH and to examine the features of complications in depth.

METHODS

 Several databases were searched for articles that matched all of the inclusion criteria. The visual analog scale (VAS) and Oswestry Disability Index (ODI) were used to assess the clinical results. Information on perioperative outcomes and complications was gathered and analyzed.

RESULTS

 Eight studies with 756 participants were included. There were no significant differences in postoperative bed time (p = 0.44) and hospitalization time (p = 0.49) between T-FELD and I-FELD. When compared with I-FELD, T-FELD was associated with substantially longer fluoroscopy time (p < 0.0001) and operating time (p < 0.0001). There were no significant differences in the preoperative and postoperative VAS and ODI scores between T-FELD and I-FELD. The rates for overall complications, postoperative dysesthesia, postoperative lower extremity pain, incomplete decompression, recurrence, and conversion to open surgery were comparable for T-FLED and I-FELD.

CONCLUSION

 T-FELD and I-FELD had equal clinical results and safety for treatment of L5-S1 LDH. Fluoroscopy and operative times were shorter for I-FELD than for T-FELD.

Transforaminal lumbar endoscopic discectomy: should we abandon it for L5-S1 foraminal and extraforaminal lumbar disc herniations? A prospective non-randomised study and literature review

PURPOSE

The aim of this study is to investigate the clinical outcomes of transforaminal lumbar endoscopic discectomy (TLED) in patients with L5-S1 lumbar disc herniation (LDH).

MATERIALS AND METHODS

Seventy-five consecutive individuals with diagnosed foraminal/extraforaminal L5-S1 LDH were included in this study. All patients underwent TLED, being subsequently evaluated in a 2-year follow-up period. Assessment was performed preoperatively and at 6 weeks and 3, 6, 12 and 24 months postoperatively. Visual Analogue Scale (distinctly applied for lower limb - VAS-LP and low back - VAS-BP pain) and Short-Form 36 (SF-36) Medical Health Survey Questionnaire were implemented to assess pain and health-related quality of life (HRQoL) of enrolled individuals, respectively.

RESULTS

No major perioperative complications were observed. Recorded values of all studied indices were demonstrated to feature a clinically and statistically significant amelioration at 6 weeks, presenting lesser improvement at 3 months with subsequent stabilisation. VAS-LP and VAS-BP values were displayed to reach a plateau in 6 months postoperatively, whereas all parameters of SF-36 continued to present a statistically significant improvement until the end of follow-up at 2 years.

CONCLUSIONS

TLED represent a safe and efficient technique in terms of diminishing perceived pain and improving HRQoL in patients with L5-S1 LDHs. However, specific patient- and technique-related circumstances on the ground of low surgical experience may limit its effectiveness in these patients.

Comparison of the Interlaminar and Transforaminal Approaches for Full-endoscopic Discectomy for the Treatment of L4/5 Lumbar Disc Herniation

This study aims to compare the outcomes of interlaminar and transforaminal approaches for full-endoscopic discectomy (FED) for treating L4/5 lumbar disc herniation (LDH).A retrospective study of patients with L4/5 LDH treated with interlaminar endoscopic lumbar discectomy (IELD, n = 19) or transforaminal endoscopic lumbar discectomy (TELD, n = 105) was conducted. Patient background, radiological findings, and operative data were collected. Oswestry Disability Index (ODI) and European Quality of Life-5 Dimension (EQ-5D) scores were recorded preoperatively and 1 and 2 years postoperatively.Although ODI and EQ-5D scores 1 and 2 years postoperatively improved statistically in the IELD and TELD groups, there were no statistical differences between the groups. IELD was predominantly performed in patients who were taller and heavier. The mean operative times and the frequency of laminectomy for IELD and TELD were 67.2 and 44.6 min and 63.2 and 17.1%, respectively (P < 0.001). The radiological findings showed that the concave configuration of the L4 lamina, interlaminar space width, and foraminal width were statistically different between the groups. There were no complications in either of the groups. Reoperation was required for recurrence in two and five patients in the IELD and TELD groups (P = 0.29), respectively.Operative outcomes were identical between the two groups. Although the operative time was longer in the IELD group, both approaches were safely and effectively performed. Depending on the patient's physique and preoperative radiological findings, the more suitable approach for L4/5 LDH should be chosen.

Coaxial radiography guided puncture technique for percutaneous transforaminal endoscopic lumbar discectomy: A randomized control trial

BACKGROUND

The coaxial radiography-guided puncture technique (CR-PT) is a novel technique for endoscopic lumbar discectomy. As the X-ray beam and the puncturing needle are maintained in a parallel and coaxial direction, the X-ray beam can be used to guide the trajectory angle, facilitating the choice of the puncture site and providing real-time guidance. This puncture technique offers numerous advantages over the conventional anterior-posterior and lateral radiography-guided puncture technique (AP-PT), especially in cases of herniated lumbar discs with a hypertrophied transverse process or articular process, high iliac crest, and narrowed intervertebral foramen.

AIM

To confirm whether CR-PT is a superior approach to percutaneous transforaminal endoscopic lumbar discectomy compared to AP-PT.

METHODS

In this parallel, controlled, randomized clinical trial, herniated lumbar disc patients appointed to receive percutaneous endoscopic lumbar discectomy treatment were recruited from the Pain Management Department of the Affiliated Hospital of Xuzhou Medical University and Nantong Hospital of Traditional Chinese Medicine. Sixty-five participants were enrolled and divided into either a CR-PT group or an AP-PT group. The CR-PT group underwent CR-PT, and the AP-PT group underwent AP-PT. The number of fluoroscopies during puncturing, puncture duration (min), surgery duration (min), VAS score during puncturing, and puncture success rate were recorded.

RESULTS

Sixty-five participants were included, with 31 participants in the CR-PT group and 34 in the AP-PT group. One participant in the AP-PT group dropped out due to unsuccessful puncturing. The number of fluoroscopies [median (P25, P75)] was 12 (11, 14) in the CR-PT group vs 16 (12, 23) in the AP-PT group, while the puncture duration (mean ± SD) was 20.42 ± 5.78 vs 25.06 ± 5.46, respectively. The VAS score was 3 (2, 4) in the CR-PT group vs 3 (3, 4) in the AP-PT group. Further subgroup analysis was performed, considering only the participants with L5/S1 segment herniation: 9 patients underwent CR-PT, and 9 underwent AP-PT. The number of fluoroscopies was 11.56 ± 0.88 vs 25.22 ± 5.33; the puncture duration was 13.89 ± 1.45 vs 28.89 ± 3.76; the surgery duration was 105 (99.5, 120) vs 149 (125, 157.5); and the VAS score was 2.11 ± 0.93 vs 3.89 ± 0.6, respectively. All the above outcomes demonstrated statistical significance (P < 0.05), favoring the CR-PT treatment.

CONCLUSION

CR-PT is a novel and effective technique. As opposed to conventional AP-PT, this technique significantly improves puncture accuracy, shortens puncture time and operation time, and reduces pain intensity during puncturing.

Nomogram for predicting the unfavourable outcomes of percutaneous endoscopic transforaminal discectomy for lumbar disc herniation: a retrospective study

Objective

To investigate and integrate multiple independent risk factors to establish a nomogram for predicting the unfavourable outcomes of percutaneous endoscopic transforaminal discectomy (PETD) for lumbar disc herniation (LDH).

Methods

From January 2018 to December 2019, a total of 425 patients with LDH undergoing PETD were included in this retrospective study. All patients were divided into the development and validation cohort at a ratio of 4:1. Univariate and multivariate logistic regression analyses were used to investigate the independent risk factors associated with the clinical outcomes of PETD for LDH in the development cohort, and a prediction model (nomogram) was established to predict the unfavourable outcomes of PETD for LDH. In the validation cohort, the nomogram was validated by the concordance index (C-index), calibration curve, and decision curve analysis (DCA).

Results

29 of 340 patients showed unfavourable outcomes in the development cohort, and 7 of 85 patients showed unfavourable outcomes in the validation cohort. Body mass index (BMI), course of disease (COD), protrusion calcification (PC), and preoperative lumbar epidural steroid injection (LI) were independent risk factors associated with the unfavourable outcomes of PETD for LDH and were identified as predictors for the nomogram. The nomogram was validated by the validation cohort and showed high consistency (C-index = 0.674), good calibration and high clinical value.

Conclusions

The nomogram based on patients' preoperative clinical characteristics, including BMI, COD, LI and PC, can be used to accurately predict the unfavourable outcomes of PETD for LDH.

Full-Endoscopic Lumbar Discectomy Approach Selection: A Systematic Review and Proposed Algorithm

STUDY DESIGN

A systematic review of the literature to develop an algorithm formulated by key opinion leaders.

OBJECTIVE

This study aimed to analyze currently available data and propose a decision-making algorithm for full-endoscopic lumbar discectomy for treating lumbar disc herniation (LDH) to help surgeons choose the most appropriate approach [transforaminal endoscopic lumbar discectomy (TELD) or interlaminar endoscopic lumbar discectomy (IELD)] for patients.

SUMMARY OF BACKGROUND DATA

Full-endoscopic discectomy has gained popularity in recent decades. To our knowledge, an algorithm for choosing the proper surgical approach has never been proposed.

MATERIALS AND METHODS

A systematic review of the literature using PubMed and MeSH terms was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Patient samples included patients with LDH treated with full-endoscopic discectomy. The inclusion criteria were interventional research (randomized and nonrandomized trials) and observation research (cohort, case-control, case series). Exclusion criteria were case series and technical reports. The criteria used for selecting patients were grouped and analyzed. Then, an algorithm was generated based on these findings with support and reconfirmation from key expert opinions. Data on overall complications were collected. Outcome measures included zone of herniation, level of herniation, and approach (TELD or IELD).

RESULTS

In total, 474 articles met the initial screening criteria. The detailed analysis identified the 80 best-matching articles; after applying the inclusion and exclusion criteria, 53 articles remained for this review.

CONCLUSIONS

The proposed algorithm suggests a TELD for LDH located in the foraminal or extraforaminal zones at upper and lower levels and for central and subarticular discs at the upper levels considering the anatomic foraminal features and the craniocaudal pathology location. An IELD is preferred for LDH in the central or subarticular zones at L4/L5 and L5/S1, especially if a high iliac crest or high-grade migration is found.

Comparison of Percutaneous Endoscopic Interlaminar Discectomy and Open Fenestration Discectomy for Single-Segment Huge Lumbar Disc Herniation: A Two-year Follow-up Retrospective Study

Purpose

Both percutaneous endoscopic lumbar discectomy (PELD) and open fenestration discectomy (OFD) are effective and safe surgical procedures for the treatment of LDH. The purpose of this retrospective study was to compare the surgical outcomes of percutaneous endoscopic interlaminar discectomy (PEID) and OFD for single-segment huge lumbar disc herniation (HLDH).

Patients and Methods

We retrospectively analyzed 91 patients diagnosed with single-segment HLDH and treated with OFD or PEID. Visual analog scale (VAS), modified Japanese orthopedic association (mJOA) and Oswestry disability index (ODI) were used to assess clinical outcomes at preoperation and postoperatively at 3, 6, 12, and 24months. Modified Macnab criteria were applied to evaluate clinically satisfaction at the final follow-up.

Results

In both groups, the VAS and ODI scores at 3, 6, 12, and 24months postoperatively showed a significant decrease and the mJOA score at 3, 6, 12, and 24months postoperatively was significantly increased compared to preoperative results (P<0.001). According to Macnab criteria at the final follow-up, the overall clinically satisfactory rate was 86.67% in the OFD group and 86.96% in the PEID group. There were no significant differences in VAS, ODI, and mJOA scores between the two groups at preoperation and postoperative 3, 6, 12, and 24months, respectively. In the PEID group, the length of hospitalization and the length of incision were significantly shorter than that in the OFD group (P<0.0001). However, there was no significant difference in operative time between groups (P=0.81).

Conclusion

Collectively, postoperative clinical results were equally favorable for both procedures, with no statistically significant difference between PEID and OFD at the two-year of follow-up. No serious complication was observed in two groups. Compared with the traditional surgery, PEID has the following benefits: less trauma, less bleeding, speedy recovery, and shorter hospitalization. Therefore, PEID may be a promising alternative to traditional surgery.