Sequestrectomy Versus Conventional Microdiscectomy for the Treatment of a Lumbar Disc Herniation: A Systematic Review

Discectomy versus sequestrectomy in the treatment of lumbar disc herniation: a systematic review and meta-analysis

BACKGROUND CONTEXT

Lumbar disc herniation (LDH) is a leading cause of low back pain (LBP) and leg pain and may require surgical treatment in case of persistent pain and/or neurological deficits. Conventional discectomy involves removing the herniated fragment and additional material from the disc space, potentially accelerating disc degeneration and contributing to chronic LBP. Conversely, by resecting the herniated fragment only, sequestrectomy may reduce postoperative LBP while increasing the risk of LDH recurrence.

PURPOSE

To compare discectomy versus sequestrectomy in terms of risk of reherniation, reoperation rate, complications, pain, satisfaction, and perioperative outcomes (operative time, blood loss, length of stay [LOS]).

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A systematic search of PubMed/MEDLINE and Scopus databases was performed through May 1, 2024 for both randomized and nonrandomized studies. The search was conducted according to PRISMA guidelines. The RoB-2 and MINORS tools were utilized to assess the risk of bias in included studies. The quality of the evidence was evaluated according to the GRADE approach. Relevant outcomes were pooled for meta-analysis.

RESULTS

A total of 16 articles (1 randomized controlled trial with 2 follow-up studies, 6 prospective studies, and 7 retrospective studies) published between 1991 and 2020 involving 2009 patients were included for analysis. No significant differences were noted between discectomy versus sequestrectomy in terms of risk of reherniation (OR: 0.85, 95% CI: 0.57 to 1.26, p=.42), reoperation rate (OR: 0.95, 95% CI: 0.64 to 1.40, p=.78), and complications (OR: 1.03, 95% CI: 0.50 to 2.11, p=.94). Although LBP (MD: -0.06, 95% CI: -0.39 to 0.28, p=.74) and leg pain intensity (MD: 0.11, 95% CI: -0.21 to 0.42, p=.50) were similar postoperatively, significantly better outcomes were reported by patients treated with sequestrectomy at 1 year (leg pain: MD: 0.37, 95% CI: 0.19 to 0.54, p<.0001) and 2 years (LBP: MD: 0.19, 95% CI: 0.03 to 0.34, p=.02; leg pain: MD: 0.20, 95% CI: 0.09 to 0.31, p=.0005). Sequestrectomy also resulted in a higher patient satisfaction (OR: 0.60, 95% CI: 0.40 to 0.90, p=.01) and shorter operative time (MD: 8.71, 95% CI: 1.66 to 15.75, p=.02), while blood loss (MD: 0.18, 95% CI: -2.31 to 2.67, p=.89) and LOS (MD: 0.02 days, 95% CI: -0.07 to 0.12, p=.60) did not significantly differ compared to discectomy.

CONCLUSIONS

Based on the current evidence, discectomy and sequestrectomy do not significantly differ in terms of risk of reherniation, reoperation rate, and postoperative complications. Patients treated with sequestrectomy may benefit from a marginally higher pain improvement, better satisfaction outcomes, and a shorter operative time, although the clinical relevance of these differences needs to be validated in larger, prospective, randomized studies.

Role of surgery in primary lumbar disk herniation: WFNS spine committee recommendations

Objective

To provide the most up-to-date recommendations on the role of surgery in first-time lumbar disk herniations (LDH) in order to standardize surgical management.

Methods

We performed a literature search in PubMed, Scopus, and Embase from 2012 to 2022 using the following keywords: "lumbar disk herniation AND surgery". Our initial search yielded 2610 results, which were narrowed down to 283 papers after standardized screening critera were applied. The data from these 283 papers were presented and discussed at two international meetings of the World Federation of Neurosurgical Societies (WFNS) Spine Committee, where the Delphi method was employed and ten spine experts voted on five final consensus statements.

Results

and Conclusions: The WFNS Spine Committee's guidelines cover four main topics: (1) role and timing of surgery in first-time LDH; (2) role of minimally invasive techniques in LDH; (3) extent of disk resection in LDH surgery; (4) role of lumbar fusion in the context of LDH. Surgery for LDH is recommended for failure of conservative treatment, cauda equina syndrome, and progressive neurological impairment, including severe motor deficits. In the latter cases, early surgery is associated with faster recovery and may improve patient outcomes. Minimally invasive techniques have short-term advantages over open procedures, but there is insufficient evidence to make a recommendation for or against the choice of a specific surgical procedure. Sequestrectomy and standard microdiscectomy demonstrated similar clinical results in terms of pain control, recurrence rate, functional outcome, and complications at short and medium-term follow-up. Lumbar fusion is not recommended as a routine treatment for first-time LDH, although it may be considered in specific patients affected by chronic axial pain or instability.

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.

Technical Considerations of Interlaminar Approach for Lumbar Disc Herniation

With the evolution of endoscopic instruments and techniques, full-endoscopic spine surgery has attracted more attention worldwide in recent years. At the initial stage, surgeons conducted endoscopic lumbar discectomy using the transforaminal approach. Next, interlaminar endoscopic lumbar discectomy was developed to treat a herniation disc at the L5-S1 level. The progression in interlaminar endoscopic techniques has further broadened the indications for full-endoscopic spine surgery. However, the steep learning curve of endoscopic procedures has remained challenging. The use of interlaminar endoscopic lumbar discectomy entails many essential skills to manage the different anatomical structures of the spine. From the perspective of successful and safe interlaminar endoscopic lumbar discectomy, we have discussed the technical considerations for endoscopic procedures.

Brake reaction time before and after surgery for patients with sequestrectomy versus conventional microdiscectomy

The aim of this study was to compare the effects of sequestrectomy versus conventional microdiscectomy on breaking response time (BRT) for lumbar disc herniation (LDH). BRT is the key factor for return to drive recommendations after surgery. A prospective clinical study was conducted. Patients aged 25-65 years who underwent surgery for lumbar disc herniation and held a valid motorcar driving license were recruited in a single institution. The patients were assessed before surgery, immediately after the surgery and at the follow up examination 30 days post-surgery. BRT was measured using a driving simulator, a visual analogue scale (VAS) was used for pain assessment. BRT values were compared with BRT values of a healthy control group. In patients treated with microdiscectomy BRT reduced from 749 (±223) msec before surgery to 649 (±223) msec immediately after the surgery. In the sequestrectomy group BRT reduced from 852 (±561) msec before surgery to 693 (±173) msec immediately after the surgery. BRT at follow up was 610 (±145) msec for patients treated with microdiscectomy and 630 (±98) msec for patients operated with sequestrectomy. BRT for healthy controls was 487 (±116) msec. Pain improved significantly for both patient samples. Sequestrectomy and microdiscectomy were associated with similar effects on pain and BRT after surgery. There was no statistically significant difference between BRT of both patient samples at 30 days follow up examination. Both surgical techniques showed a positive effect on BRT. No statistically significant difference between sequestrectomy and microdiscectomy on BRT could be found.

Closing the Treatment Gap for Lumbar Disc Herniation Patients with Large Annular Defects: A Systematic Review of Techniques and Outcomes in this High-risk Population

Lumbar disc herniation (LDH) is one of the most common spinal pathologies and can be associated with debilitating pain and neurological dysfunction. Discectomy is the primary surgical intervention for LDH and is typically successful. Yet, some patients experience recurrent LDH (RLDH) after discectomy, which is associated with worse clinical outcomes and greater socioeconomic burden. Large defects in the annulus fibrosis are a significant risk factor for RLDH and present a critical treatment challenge. It is essential to identify reliable and cost-effective treatments for this at-risk population. A systematic review of the PubMed and Embase databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies describing the treatment of LDH patients with large annular defects. The incidence of large annular defects, measurement technique, RLDH rate, and reoperation rate were compiled and stratified by surgical technique. The risk of bias was scored for each study and for the identification of RLDH and reoperation. Study heterogeneity and pooled estimates were calculated from the included articles. Fifteen unique studies describing 2,768 subjects were included. The pooled incidence of patients with a large annular defect was 44%. The pooled incidence of RLDH and reoperation following conventional limited discectomy in this population was 10.6% and 6.0%, respectively. A more aggressive technique, subtotal discectomy, tended to have lower rates of RLDH (5.8%) and reoperation (3.8%). However, patients treated with subtotal discectomy reported greater back and leg pain associated with disc degeneration. The quality of evidence was low for subtotal discectomy as an alternative to limited discectomy. Each report had a high risk of bias and treatments were never randomized. A recent randomized controlled trial with 550 subjects examined an annular closure device (ACD) and observed significant reductions in RLDH and reoperation rates (>50% reduction). Based on the available evidence, current discectomy techniques are inadequate for patients with large annular defects, leaving a treatment gap for this high-risk population. Currently, the strongest evidence indicates that augmenting limited discectomy with an ACD can reduce RLDH and revision rates in patients with large annular defects, with a low risk of device complications.

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

Purpose

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

Materials and Methods

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

Results

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

Conclusions

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

Predictors of an unfavorable outcome 1.5 and 12 years after a first, uncomplicated lumbar disc surgery

PURPOSE

To identify predictors of both intermediate and long-term unfavorable outcomes after first time, uncomplicated lumbar disc surgery.

METHODS

Patients (n = 120) who had undergone lumbar disc surgery were followed up 1.5 and 12 years thereafter. Baseline assessments were carried out 5-8 days after surgery. Clinical outcome was assessed in both follow-ups using the Low Back Pain Rating Scale. Statistical analysis included binary logistic and linear regression.

RESULTS

Unfavorable outcomes were found in 50.5 % (1.5 years) and 52.6 % (12 years) of patients available for follow-up examination. Low pre-operative physical activity and severe pain in the first week after surgery were predictive of an unfavorable post-operative outcome at both follow-ups.

CONCLUSIONS

Identified predictors suggest that particular emphasis should put on comprehensive post-operative care at large and encouragement to adapt a physically active lifestyle in particular in rehabilitation concepts after first time uncomplicated lumbar disc surgery.