Comparison of the effectiveness and outcome of microendoscopic and open discectomy in patients suffering from lumbar disc herniation

Patient-Reported Outcomes and Return to Work after CT-Guided Percutaneous Lumbar Discectomy: A Prospective Study

PURPOSE

To evaluate the effectiveness of percutaneous lumbar discectomy (PLD) under computed tomography (CT) guidance on pain and functional capacities and to estimate the speed of recovery by assessing the time to return to work.

MATERIALS AND METHODS

Patients treated with PLD were prospectively included between December 2019 and April 2021. Data regarding pain, duration of symptoms, analgesia intakes, time of absence from work, and the Oswestry disability index (ODI) were collected. Patients were followed-up during 6 months. Duration of hospitalization and time to return to work were reported. The Fisher test was used to compare nominal variables, the Kruskal-Wallis test to compare ordinal variables, and the Student t test to compare quantitative continuous variables.

RESULTS

A total of 87 patients were evaluated (median age, 56 years; interquartile range [IQR], 43-66 years). The median ODI decreased from 44 (IQR, 33-53) to 7 (IQR, 2-17) at 6 months (P < .001). The median visual analog scale score decreased from 8 (IQR, 8-9) to 2 (IQR, 0-3) within 6 months (P < .001). In total, 96.5% of patients were discharged on the day of the procedure, and 3.5% were discharged on the following day. No severe adverse events were reported according to the Society of Interventional Radiology (SIR) classification system. Of the 57 patients previously employed, 50 were able to return to work during the follow-up, with a median time of 8 days (IQR, 0-20 days).

CONCLUSIONS

Symptomatic lumbar disc herniation can be successfully treated using PLD, resulting in significant improvement in symptoms and functional capacities and a fast return to work.

Differential Agnostic Effect Size Analysis of Lumbar Stenosis Surgeries

STUDY DESIGN

A meta-analysis of 89 randomized prospective, prospective, and retrospective studies on spinal endoscopic surgery outcomes.

OBJECTIVE

The study aimed to provide familiar Oswestry Disability Index (ODI), visual analog scale (VAS) back, and VAS leg effect size (ES) data following endoscopic decompression for sciatica-type back and leg pain due to lumbar herniated disc, foraminal, or lateral recess spinal stenosis.

BACKGROUND

Higher-grade objective clinical outcome ES data are more suitable than lower-grade clinical evidence, including cross-sectional retrospective study outcomes or expert opinion to underpin the ongoing debate on whether or not to replace some of the traditional open and with other forms of minimally invasive spinal decompression surgeries such as the endoscopic technique.

METHODS

A systematic search of PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials from 1 January 2000 to 31 December 2019 identified 89 eligible studies on lumbar endoscopic decompression surgery enrolling 23,290 patient samples using the ODI and VAS for back and leg pain used for the ES calculation.

RESULTS

There was an overall mean overall reduction of ODI of 46.25 (SD 6.10), VAS back decrease of 3.29 (SD 0.65), and VAS leg reduction of 5.77 (SD 0.66), respectively. Reference tables of familiar ODI, VAS back, and VAS leg show no significant impact of study design, follow-up, or patients' age on ES observed with these outcome instruments. There was no correlation of ES with long-term follow-up (P = 0.091). Spinal endoscopy produced an overall ODI ES of 0.92 extrapolated from 81 studies totaling 12,710 patient samples. Provided study comparisons to tubular retractor microdiscectomy and open laminectomy showed an ODI ES of 0.9 (2895 patients pooled from 16 studies) and 0.93 (1188 patients pooled from 5 studies). The corresponding VAS leg ES were 0.92 (12,631 endoscopy patients pooled from 81 studies), 0.92 (2348 microdiscectomy patients pooled from 15 studies), and 0.89 (1188 open laminectomy patients pooled from 5 studies).

CONCLUSION

Successful clinical outcomes can be achieved with various lumbar surgeries. ESs with endoscopic spinal surgery are on par with those found with open laminectomy and microsurgical decompression.

CLINICAL RELEVANCE

This article is a meta-analysis on the benefit overlap between lumbar endoscopy, microsurgical decompression, laminectomy, and lumbar decompression fusion.

LEVEL OF EVIDENCE: 2

Does MIS-TLIF or TLIF result in better pedicle screw placement accuracy and clinical outcomes with navigation guidance?

Background

Although previous studies have suggested that navigation can improve the accuracy of pedicle screw placement, few studies have compared navigation-assisted transforaminal lumbar interbody fusion (TLIF) and navigation-assisted minimally invasive TLIF (MIS-TLIF). The entry point of pedicle screw insertion in navigation-assisted MIS-TLIF (NM-TLIF) may deviate from the planned entry point due to an uneven bone surface, which may result in misplacement. The purpose of this study was to explore the pedicle screw accuracy and clinical consequences of MIS-TLIF and TLIF, both under O-arm navigation, to determine which surgical method is better.

Methods

A retrospective study of 54 patients who underwent single-segment NM-TLIF or navigation-assisted TLIF (N-TLIF) was conducted. In addition to the patients’ demographic characteristics, intraoperative indicators and complications, the Oswestry Disability Index (ODI) and visual analog scale (VAS) score were recorded and analyzed preoperatively and at the 1-, 6-, and 12-month and final postoperative follow-ups. The clinical qualitative accuracy and absolute quantitative accuracy of pedicle screw placement were assessed by postoperative CT. Multifidus muscle injury was evaluated by T2-weighted MRI.

Results

Compared with N-TLIF, NM-TLIF was more advantageous in terms of the incision length, intraoperative blood loss, drainage volume, time to ambulation, length of hospital stay, blood transfusion rate and analgesia rate (P < 0.05). The ODI and VAS scores for low back pain were better than those of N-TLIF at 1 month and 6 months post-surgery (P < 0.05). There was no significant difference in the clinical qualitative screw placement accuracy (97.3% vs. 96.2%, P > 0.05). The absolute quantitative accuracy results showed that the axial translational error, sagittal translational error, and sagittal angle error in the NM-TLIF group were significantly greater than those in the N-TLIF group (P < 0.05). The mean T2-weighted signal intensity of the multifidus muscle in the NM-TLIF group was significantly lower than that in the N-TLIF group (P < 0.05).

Conclusions

Compared with N-TLIF, NM-TLIF has the advantages of being less invasive, yielding similar or better screw placement accuracy and achieving better symptom relief in the midterm postoperative recovery period. However, more attention should be given to real-time adjustment for pedicle insertion in NM-TLIF rather than just following the entry point and trajectory of the intraoperative plan.

[Two treatment approaches for lumbar disc herniation and sequester migration to the second and third McCulloch's windows: transpedicular and translaminar sequestrectomy (ridit analysis)]

A ridit analysis of results of transpedicular endoscopic and translaminar microsurgical surgeries for sequester migration to the second and third McCulloch's windows was carried out. The authors assessed pain syndrome, quality of life and neurological impairment.

OBJECTIVE

To compare the outcomes of transpedicular and translaminar sequestrectomy for lumbar disc herniation and sequester migration to the second and third McCulloch's windows.

MATERIAL AND METHODS

We analyzed treatment outcomes in 51 patients with lumbar disc herniation and severe sequester migration. We assessed lumbar and leg pain syndrome using then visual analogue scale, neurological impairment using the adapted Nurik scale and quality of life using the Oswestry questionnaire and the MacNab scale in early postoperative period, as well as in 2 weeks, 6 and 12 months after surgery. Ridit analysis was used for statistical processing of data.

RESULTS

Transpedicular sequestrectomy was performed in 24 patients, translaminar sequestrectomy - in 27 cases. Groups were comparable by gender, size and location of sequestration, somatic and neurological status, as well as pain severity. There was a higher probability of back (0.39) and leg (0.364) pain regression, neurological recovery (0.446) and improvement of quality of life according to the Oswestry questionnaire (0.389) after transpedicular surgery. According to the MacNab scoring system, excellent and good results were obtained in 84.21% and 15.79% of patients in 6 months after transpedicular surgery. In the second group, excellent, good and satisfactory results were obtained in 63%, 25.9% and 11.1% of patients, respectively.

CONCLUSION

Herniated intervertebral discs with severe sequester migration should be divided in accordance with localization of the main sequestration. Transpedicular endoscopic approach is advisable for sequester in the third and rarely the second McCulloch's windows. Translaminar microsurgical approach is preferred for sequestration in the second and rarely the third McCulloch's windows. Clinical outcomes after translaminar microsurgical sequestrectomy and transpedicular endoscopic surgeries are similar. However, postoperative back and leg pain regression, neurological recovery and improvement of quality of life according to the Oswestry scoring system are more common after transpedicular surgery.

Comparative Study between Full-Endoscopic Discectomy and Microendoscopic Discectomy for the Treatment of Lumbar Disc Herniation

Background and objectives: Lumbar disc herniation (LDH) is a common disease in the meridian of life. Although surgical discectomy is commonly used to treat LDH, there are several different strategies. We compared the outcomes of uniportal full-endoscopic discectomy (FED) with those of microendoscopic discectomy (MED) in treating LDH. Materials and Methods: FED was performed using a 4.1-mm working channel endoscope, and MED was performed using a 16-mm diameter tubular retractor and endoscope. Data of patients with LDH treated with FED (n = 39) or MED (n = 27) by the single surgeon were retrospectively reviewed. Patient background information and operative data were collected. Pre- and postoperative low back and leg pain were evaluated using the numerical rating scale (NRS) score. Pre- and postoperative disc height index (DHI) values were calculated from plain radiographs, and the disc height loss was evaluated using the ratio (DHI ratio); Results: The median (interquartile range (IQR) Q25–75) operation times for FED and MED were 42 (33–61) and 43 (33–50) minutes, respectively. The median (IQR Q25–75) pre- and postoperative NRS scores for low back pain were 5 (2–7) and 1 (0–4), respectively, for FED and 6 (3–8) and 1 (0–2), respectively, for MED. The median (IQR Q25–75) pre- and postoperative NRS scores for leg pain were 7 (5–8) and 0 (0–2), respectively, for FED and 6 (5–8) and 0 (0–2), respectively, for MED. These data were not different between the FED and MED groups. The median (IQR Q25–75) DHI ratios of FED and MED were 0.94 (0.89–1.03) and 0.90 (0.79–0.95), respectively. The DHI ratio was significantly higher (p < 0.05) in the FED group than in the MED group, and there was less blood loss; Conclusions: The pain-relieving effect of FED in treating LDH was almost identical to that of MED. However, FED was superior to MED in preventing disc height loss, which is one of the indicators of postoperative disc degeneration.

Minimally Invasive Versus Open Surgery for Degenerative Spine Disorders for Elderly Patients: Experiences from a Single Institution

BACKGROUND

Minimally invasive surgery (MIS) of the spine has been associated with lower complication rates and improved patient-reported outcomes in recent studies. In this study, we aimed to investigate operative and postoperative outcomes associated with both surgical techniques in elderly patients.

METHODS

Patients who are 65 years old or older underwent either minimally invasive or open surgery for lumbar degenerative conditions. Patients with a nondegenerative cause such as infection or trauma were excluded from the analysis. Patient characteristics such as demographics and associated comorbidities as well as perioperative and postoperative complications were collected. Outcomes of interest were operative time, estimated blood loss (EBL), length of stay (LOS), readmissions, reoperations, and any complications.

RESULTS

A total of 107 elderly patients were identified for this study, with a median age of 73.0 years. Demographics and comorbidities in both groups were similar in both groups. Univariate analysis yielded an MIS group with significantly lower EBL (P < 0.001), operative time (P < 0.001), and LOS (P < 0.001). In multivariable analysis, EBL and LOS were found to be significantly lower in the MIS group (P = 0.02 and 0.001, respectively). Rates of complications, readmissions (no readmissions in MIS group), reoperations, and pain improvement also favored the MIS group and although they were not found to be significantly different between the 2 groups on univariate and multivariable analysis, the results trended toward significance.

CONCLUSIONS

These findings suggest that minimally invasive spine surgery in the elderly is safe and may pose a lower risk of associated perioperative and postoperative complications with faster recovery time.

The effectiveness of high intensity laser therapy in the patients with lumbar disc herniation: A protocol of randomized placebo-controlled trial

BACKGROUND

There is no consensus in existing literature on the pulse power, application time, frequency and the dose of energy of laser therapy for the patients. Therefore, we conducted this research for the assessment of safety and efficiency of ultrasound and high-intensity laser therapy (HILT) in the lumbar disc herniation (LDH) patients.

METHODS

Our present research was approved by the institutional review board in the West China-Guangan Hospital. All the participants would acquire the written informed consent. From December 2020 to December 2021, we will conduct a prospective evaluation via a senior surgeon for 1 hundred LDH patients who plan to undergo the conservative treatment at our hospital. In this research, the inclusion criteria contained: the patients with lumbar disc herniation diagnosed by lumbar MRI; the patients with no history of trauma or congenital abnormalities; and the patients with sufficient psychological ability to understand and then answer the questions raised in assessment scale. The participants were randomly divided into the control group or HILT group after performing the examination of baseline. The main outcome was the pain score of visual analog scale. The other results contained the adverse effects, back range of motion as well as functional scores.

CONCLUSIONS

We assumed that the HILT is as effective as the ultrasound therapy in treating pain for LDH.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5975).

A randomized study protocol of microendoscopic versus open discectomy in treatment of lumbar disc herniation

BACKGROUND

Lumbar disk herniation (LDH) is one of the main causes of discogenic low back pain. However, the evidence comparing different approaches for discectomy has lacked definitive conclusions, with conflicting results regarding the benefit of minimally invasive versus open techniques for LDH. We are now conducting a randomized controlled trial to figure out whether or not microendoscopic discectomy yields better clinical outcomes and causes less surgical trauma than open surgery.

METHODS

This prospective, randomized, single-blind, controlled, superiority clinical trial was approved by the institutional review board in the People's Hospital of Jianyang City. The conduct of this study followed the Declaration of Helsinki principles and the reporting of this study adhered to the Consolidated Standards of Reporting Trials guidelines for randomized controlled trials. Subjects were randomized into 2 groups as follows: open surgery and microendoscopic group. The outcomes included pain score, functional outcome, satisfaction rate, radiological outcomes, and complications. The statistical analyses in this study were performed using the Statistical Package for the Social Sciences 20.0 software. P < .05 was accepted as statistically significant.

RESULTS

The hypothesis was that the open technique would achieve similar clinical outcomes as compared to the microendoscopic technique in LDH.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5708).

Efficacy and safety of epidural steroid injection following discectomy for patients with lumbar disc herniation: A protocol

BACKGROUND

Concerns exist regarding the analgesia effect and safety of epidural steroid injection (ESI) after discectomy. There is an urgent need of studies that efficiently control for confounding, conduct comprehensive and consecutive observation of potential risks of ESI, and investigate its clinical applicability. We thus further designed a randomized controlled study to assess the efficacy of ESI on postoperative pain and complications in patients undergoing unilateral lumbar microdiscectomy.

METHODS

This prospective, blinded randomized controlled trial was conducted at our single hospital. This study was approved by the Committee at the No.2 People's Hospital of Yibin. All procedures were performed by a single surgeon and informed consent was obtained from each patient. Ninty eligible patients diagnosed at our institution with herniated lumbar disc during a period from June 2020 to July 2021 will be assessed. Group 1 was a mixture of 1 mL of 0.5% bupivacaine and 10 mg of triamcinolone acetonide in 1 mL. Group 2 was a mixture of 1 mL of 0.5% bupivacaine and 1 mL of normal saline. The primary outcome measure was the amount of morphine consumption from a patient-controlled analgesia pump at 12, 24, and 48 hours after surgery. The following secondary outcomes were also assessed: postoperative pain score, back pain score, functional disability, and adverse effect.

CONCLUSIONS

We hypothesized that the ESI was associated with lower pain score, morphine consumption, and hospital stay, with no significant difference in complications for ESI application after lumbar discectomy in lumbar disc herniation when compared with placebo.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5683).