Micro-endoscopic discectomy versus percutaneous endoscopic surgery for lumbar disk herniation

Spontaneous Resolution of Symptomatic Synovial Cysts of the Lumbar Spine: A Comprehensive Review with Two Illustrative Cases

Although lumbar synovial cysts (LSCs) are frequently described in the literature, they are a relatively uncommon cause of low back and radicular leg pain. Furthermore, their spontaneous resolution is an even rarer event. The standard treatment of the lumbar synovial cyst is surgical excision. Spontaneous resolution in the literature is a sporadic event. In our experience, we have had two cases where the lumbar synovial cyst disappeared spontaneously. To date, only nine cases of spontaneous resolution of synovial cysts have been documented in the literature. In this discussion, we highlight a pathology that typically suggests surgical intervention, yet conservative treatment can be a viable alternative. We present two cases of large synovial cysts that were initially scheduled for surgery but ultimately resolved spontaneously without any treatment. While the spontaneous resolution of lumbar synovial cysts is extremely rare, conservative strategies are an option that should not be overlooked. Our cases contribute to the growing body of evidence on the spontaneous regression of symptomatic LSC, potentially enhancing the understanding of the disease's natural progression in the future.

Comparison of the Outcomes of Microendoscopic Discectomy Versus Full-Endoscopic Discectomy for the Treatment of L4/5 Lumbar Disc Herniation

STUDY DESIGN

Retrospective Comparative Study.

OBJECTIVES

To compare the outcomes of microendoscopic discectomy (MED) versus full-endoscopic discectomy (FED) for treating L4/5 lumbar disc herniation (LDH).

METHODS

A retrospective study was performed on patients with L4/5 LDH treated using MED (n = 249) or FED (n = 124). A 16-mm tubular retractor and endoscope was used for MED, while a 4.1-mm working channel endoscope was used for FED. Patient background and operative data were collected. The Oswestry Disability Index (ODI) and European Quality of Life-5 Dimensions (EQ-5D) scores were recorded preoperatively and at 1 and 2 years postsurgery.

RESULTS

The background data of the two groups were similar. The mean operation times for MED and FED were 59.3 and 47.7 min (respectively), and the mean volumes of removed nucleus pulposus were .65 and 1.03 g, respectively. These differences were significant (P < .001). Six dural tears and one postoperative hematoma were observed in the MED group; none were observed in the FED group. During the follow-up period, 16 MED and 7 FED patients required re-operation due to recurrence (P = 1.00). Although the ODI and EQ-5D scores significantly improved at 1 and 2 years postsurgery in both groups, the differences were not statistically significant.

CONCLUSIONS

Operative outcomes were almost identical in both groups. We did not observe any operative or postoperative complications in FED. We, therefore, recommend FED as the first option for the treatment of L4/5 LDH since it has a better safety profile and is minimally invasive.

Unilateral biportal endoscopic lumbar interbody fusion (ULIF) versus endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) in the treatment of lumbar spinal stenosis along with intervertebral disc herniation: a retrospective analysis

OBJECTIVE

This study aims to compare the clinical effects and imaging data of patients who underwent endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) with those who received unilateral biportal endoscopic lumbar interbody fusion (ULIF).

METHODS

A retrospective analysis was conducted on the clinical data of 69 patients presenting with typical intermittent claudication and signs and symptoms indicative of unilateral lower extremity nerve root compression, meeting inclusion criteria between April 2022 and June 2022. Among the cohort, 35 patients underwent ULIF group, while 34 patients underwent Endo-TLIF group. We compared perioperative parameters, including intraoperative blood loss, duration of hospital stay, and operation time between the two groups. Pre-operative and post-operative changes in the height and cross-sectional area of the target intervertebral space were also compared between the groups. Finally, we evaluated bone graft size and interbody fusion rates at 6 and 12 months post-surgery using the Brantigan scoring system.

RESULTS

The ULIF group had significantly shorter operative times compared to the Endo-TLIF group (P < 0.05). Conversely, the Endo-TLIF group exhibited significantly shorter hospital stays compared to the ULIF group (P < 0.05). However, there were no significant differences in intraoperative bleeding between the two groups (P > 0.05). Furthermore, both groups exhibited postoperative increases in vertebral canal volume compared to baseline (P < 0.05), with no significant difference in the change in the cross-sectional area of the target intervertebral space between the two surgical methods (P > 0.05). Interbody fusion rates were comparable between the two groups at both 6 and 12 months after surgery (P > 0.05). Lastly, the ULIF group had a significantly larger area of bone graft than the Endo-TLIF group (P < 0.05).

CONCLUSION

In summary, the ULIF technique, as a novel spinal endoscopy approach, is a safer and more effective minimally invasive surgical method for addressing lumbar spinal stenosis and intervertebral disc herniation in patients. Both surgical methods have their own advantages and drawbacks. With the development of technology and related instruments, the limitations of both techniques can be mitigated for to a certain extent, and they can be applied by more doctors in diverse medical fields in the future.

Reference values of lumbar spine range of motion by sex and age based on the assessment of supine trunk lateral bending-A preliminary study

[Purpose] The purpose of this study was to clarify the preliminary reference values for the lumbar spine range of motion associated with lateral bending exercises by gender and age group. [Methods] Subjects were 82 volunteers without low back pain, including five males and five females in each age group from 16-19 to 80-89 years. All subjects underwent radiographs of the lumbar spine with lateral flexion; the range of lateral flexion of the vertebrae from T12 to the sacrum (ROLB) was measured twice by three observers. [Results] The ROLB of the entire T12-S1 of all subjects showed a significant negative correlation with age in both sexes (p < 0.01). The ROLB of the lumbar spine tended to be greater in females, with a statistically significant difference between those aged 16-19 and 70-79 (p < 0.05). Lateral flexion angles for each intervertebral segment were largest at L3-L4 and smallest at L5-S1 (0.7°). [Conclusion] Lumbar ROLB reference values were examined by gender and age group; ROLB was greatest in L3-L4, and ROLB tended to be lower in older age groups.

A systematic review and bibliometric study of Bertolotti's syndrome: clinical characteristics and global trends

PURPOSE

Bertolotti's syndrome is a prevalent congenital deformity. However, many physicians fail to include it in their differential diagnosis for low back pain (LBP), which results in missed diagnosis or misdiagnosis. There is still a lack of standardized treatment and management strategies for Bertolotti's syndrome. This study aimed to review the clinical characteristics and management of Bertolotti's syndrome and reports bibliometric insights in advancements in Bertolotti's syndrome research.

METHODS

Studies published until 30 September 2022 were systematically reviewed according to the PRISMA guidelines. Three independent reviewers extracted the data and assessed the quality and risk of bias of the studies based on the methodological index of non-randomized studies (MINORS). SPSS, VOS viewer, and the Citespace software were used for the systematic review, visual analysis, data mining, mapping, and clustering of the retrieved articles, which presented clear and visual presentations of the structural patterns of published research in graphs.

RESULT

A total of 118 articles, describing a total of 419 patients with Bertolotti's syndrome, were included. There was an upward trend with a steady increase in the number of publications. The world map distribution showed that most publications were predominantly from North America and Asia. The most cited articles were published in the following journals: Spine, J Bone Joint Surg, and Radiology. The mean age of the patients was 47.7 years, and 49.6% of them were male. A total of 159 (96.4%) patients had LBP symptoms. The mean symptom duration was 41.4 months (74.8%), and most of the patients had Castellvi type II. Disc degeneration was the most reported comorbid spinal diseases. The mean methodological index of non-randomized studies score was 4.16±3.95 points (range, 1-21). A total of 265 (68.3%) patients underwent surgical treatments. Minimally invasive surgical techniques, prevalence, image classification, and disc degeneration were the current main research areas of Bertolotti's syndrome.

CONCLUSIONS

The steady increase in the number of publications demonstrated the increased attention of researchers on this topic. Our results showed a significant prevalence of Bertolotti's syndrome in patients with LBP and a long symptom duration before the initiation of treatment. Surgical treatments were commonly used to treat patients with Bertolotti's syndrome after a non-effective conservative treatment. Minimally invasive surgical techniques, prevalence, image classification, and disc degeneration are the major research areas of Bertolotti's syndrome.

[Comparison of effectiveness between unilateral biportal endoscopic lumbar interbody fusion and endoscopic transforaminal lumbar interbody fusion for lumbar spinal stenosis combined with intervertebral disc herniation]

Objective

To compare the effectiveness between unilateral biportal endoscopic lumbar interbody fusion (ULIF) and endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) in treatment of lumbar spinal stenosis combined with intervertebral disc herniation.

Methods

A clinical data of 64 patients with lumbar spinal stenosis and intervertebral disc herniation, who were admitted between April 2020 and November 2021 and met the selection criteria, was retrospectively analyzed. Among them, 30 patients were treated with ULIF (ULIF group) and 34 patients with Endo-TLIF (Endo-TLIF group). There was no significant difference in baseline data such as gender, age, disease duration, lesion segment, preoperative visual analogue scale (VAS) score of low back pain and leg pain, Oswestry disability index (ODI), spinal canal area, and intervertebral space height between the two groups ( P>0.05). The operation time, intraoperative blood loss, hospital stays, and postoperative complications were compared between the two groups, as well as the VAS scores of low back pain and leg pain, ODI, and imaging measurement indicators (spinal canal area, intervertebral bone graft area, intervertebral space height, and degree of intervertebral fusion according to modified Brantigan score).

Results

Compared with the Endo-TLIF group, the ULIF group had shorter operation time, but had more intraoperative blood loss and longer hospital stays, with significant differences ( P<0.05). The cerebrospinal fluid leakage occurred in 2 cases of Endo-TLIF group and 1 case of ULIF group, and no other complication occurred. There was no significant difference in the incidence of complications between the two groups ( P>0.05). All patients in the two groups were followed up 12 months. The VAS scores of lower back pain and leg pain and ODI in the two groups significantly improved when compared with those before operation ( P<0.05), and there was no significant difference between different time points after operation ( P>0.05). And there was no significant difference between the two groups at each time point after operation ( P>0.05). Imaging examination showed that there was no significant difference between the two groups in the change of spinal canal area, the change of intervertebral space height, and intervertebral fusion rate at 6 and 12 months ( P>0.05). The intervertebral bone graft area in the ULIF group was significantly larger than that in the Endo-TLIF group ( P<0.05).

Conclusion

For the patients with lumbar spinal stenosis combined with intervertebral disc herniation, ULIF not only achieves similar effectiveness as Endo-TLIF, but also has advantages such as higher decompression efficiency, flexible surgical instrument operation, more thorough intraoperative intervertebral space management, and shorter operation time.

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.

Recent Updates on Minimally Invasive Spine Surgery: Techniques, Technologies, and Indications

A number of minimally invasive spine surgeries (MISSs) have been developed to address the drawbacks of open spine surgery. Their advantages include small skin incisions, reduction in tissue damage, quick recovery, and short hospital stay. However, the clinical outcomes are comparable to open surgery. There was a cap on the number of indications that could be set for all spinal illnesses. The indications for MISSs have been expanding owing to mechanical and technological advances in medical equipment. Thus, this review presents the various MISSs developed to date, surgical indications, surgical techniques, and their advantages and disadvantages.

Microendoscopic lumbar discectomy with general versus local anesthesia: A systematic review and meta-analysis

Background

While general anesthesia (GA) is the most commonly used anesthetic method during lumbar microendoscopic discectomy (MED), local ± epidural anesthesia (LA) has been gaining popularity as an alternate method. Theoretical advantages of LA include reduced morbidity of anesthesia and improved surgeon-patient communication facilitating less nerve root manipulation and yielding improved surgical outcomes. The objective of this systematic review is to examine the impact of anesthesia type on patient reported outcomes (PROs) and complications with MED.

Methods

A systematic review and meta-analysis of the available literature examining MED performed under GA or LA was performed. The PubMed, EMBASE and SCOPUS databases were searched from inception to August 16, 2021, utilizing strict inclusion and exclusion criteria with all studies reporting greater than 6 months of follow-up and PRO data. PROs including Visual Analog Scale (VAS)-leg/back, Oswestry Disability Index (ODI), Japanese Orthopedic Association (JOA) and/or 36-Item Short Form (SF-36) physical component scores were collected. Complication, recurrent disc herniation, durotomy and reoperation rates as well as surgical factors were collected. All outcomes were compared between pooled studies examining GA or LA. Risk of bias was assessed with the Newcastle-Ottawa Scale.

Results

A total of 23 studies consisting of 2,868 patients (1,335 GA, 1,533 LA) were included in the meta-analysis. There were no significant differences between GA and LA groups in regard to overall complication rate, durotomy rate, recurrent disc herniation rate, reoperation rate, blood loss, or surgical time (p > 0.05). Both groups demonstrated significant improvements in ODI and JOA (p<0.0004), however leg and back VAS was only improved in GA (p<0.0025) and not in LA (p>0.058), and SF-36 only in LA (p=0.003).

Conclusions

Patients undergoing MED under both anesthetic techniques demonstrated significant improvements in ODI and JOA, with no significant differences in complication or reoperation rates. However, patients undergoing GA demonstrated significant improvement in VAS leg and back pain at last follow-up while LA did not. LA may be offered to carefully selected patients and prior studies have demonstrated reduced costs and risks with LA. Conclusions are limited by a high level of study bias and heterogeneity. Further investigation is needed to assess the true effects of GA and LA on outcomes after MED.

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

Comparison of microendoscopic discectomy and percutaneous transforaminal endoscopic discectomy for upper lumbar disc herniation: A protocol for a systematic review and meta-analysis

BACKGROUND

Microendoscopic discectomy (MED) and percutaneous transforaminal endoscopic discectomy (PTED), as two alternative surgical techniques in minimally invasive spine surgery (MISS), are widely conducted in the treatment of upper lumbar disc herniation (ULDH). This study will systematically assess and compare the clinical outcomes of MED and PTED in treating ULDH combining with the meta-analysis.

METHODS

All the randomized controlled trials (RCTs) will be searched at the databases including PubMed, EMBASE, Cochrane Library and Web of Science, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), Chinese Scientific Journal Database (VIP), and WANFANG Database from inception to December 2025. The primary outcome will involve Japanese Orthopedic Association (JOA), Oswestry disability index (ODI), and visual analog scale (VAS) scores. The secondary outcomes will be the short-form 36-item (SF-36) health survey questionnaire and the modified MacNab criterion. We will perform data synthesis, subgroup analysis, sensitivity analysis, meta-regression analysis, and the assessment of reporting bias using RevMan 5.3 software.

RESULTS

This systematic review will comprehensively evaluate the clinical outcomes of comparison of MED and PTED in the treatment of ULDH and provide a reliable and high-quality evidence.

CONCLUSION

The conclusion of this study will elucidate the clinical outcomes of MED compared with PTED and clarify whether PTED generates better clinical effects than MED in treating ULDH.

PROSPERO REGISTRATION NUMBER

CRD 42021244204.

A systematic review of full endoscopic versus micro-endoscopic or open discectomy for lumbar disc herniation

Aim: Endoscopic discectomies provide several advantages over other techniques such as traditional open lumbar discectomy (OLD) including possibly decreased complications, shorter hospital stay and an earlier return to work. Methods: An electronic database search including MEDLINE/PubMed, EMBASE, Scopus, Cochrane Database of Systematic Reviews and Cochrane Controlled trials (CENTRAL) were reviewed for randomized controlled trials (RCTs) only. Results: A total of nine RCTs met inclusion criteria. Three showed benefit of endoscopic discectomy over the comparator with regards to pain relief, with the remaining six studies showing no difference in pain relief or function. Conclusion: Based on review of the nine included studies, we can conclude that endoscopic discectomy is as effective as other surgical techniques, and has additional benefits of lower complication rate and superior perioperative parameters.

Momentary pain assessments reveal benefits of endoscopic discectomy: a prospective cohort study

Both pain rating and exponential model revealed that percutaneous endoscopic lumbar discectomy provided rapid pain recovery that was maintained for at least 3 months compared with conservative treatments.

Lumbar disc herniation (LDH) is a common back disorder that evokes back and/or leg pain. Percutaneous endoscopic lumbar discectomy (PELD) is a minimally invasive surgery for patients with LDH. However, there is little evidence of effectiveness of PELD compared with conservative treatments.

Percutaneous Transforaminal Endoscopic Discectomy Versus Microendoscopic Discectomy for Lumbar Disc Herniation: Two-Year Results of a Randomized Controlled Trial

STUDY DESIGN

A prospective randomized controlled study.

OBJECTIVE

To clarify whether percutaneous transforaminal endoscopic discectomy (PTED) has better clinical outcomes and less surgical trauma compared with microendoscopic discectomy (MED).

SUMMARY OF BACKGROUND DATA

Two kinds of minimally invasive spine surgeries, PTED and MED, are now widely used for the treatment of lumbar disc herniation (LDH). It is still a controversial issue to choose the proper surgical approach.

METHODS

In this single-center, open-label, randomized controlled trial, patients were included if they had persistent signs and symptoms of radiculopathy with corresponding imaging-confirmed LDH, and were randomly allocated to PTED or MED group. The primary outcome was the score of Oswestry Disability Index (ODI) and the secondary outcomes included the score of Medical Outcomes Study 36-Item Short-Form Health Survey bodily pain and physical function scales, European Quality of Life-5 Dimensions, and Visual Analogue Scales for back pain and leg pain.

RESULTS

A total of 250 participants were randomly assigned to two treatment groups, 241 of that received the specific surgical procedure. Two hundred twenty-two patients (92.1%) have completed the 2-year follow-up. Both the primary and secondary outcomes did not differ significantly between the two treatment groups at each prespecified follow-up time (P > 0.05). For PTED, the postoperative improvement of ODI score in the median herniation subgroup was less compared with paramedian subgroup. For MED, less improvement of ODI score was found in far-lateral herniation subgroup compared with paramedian subgroup. Total complication rate over the course of 2 year was 13.44% in PTED group and 15.57% in MED group (P = 0.639). Ten cases (8.40%) in PTED group and five cases (4.10%) in MED group suffered from residue/recurrence of herniation, for which reoperation was required.

CONCLUSION

Over the 2-year follow-up period, PTED did not show superior clinical outcomes and did not appear to be safer procedure for patients with LDH compared with MED. PTED had inferior results for median disc herniation, whereas MED did not appear to be the best option for far-lateral disc herniation.

LEVEL OF EVIDENCE

2.

[Effect of Quantitative indicators of ilium height on approach of percutaneous endoscopic lumbar discectomy treatment in patients with L 5, S 1 lumbar disc herniation]

Objective

To identify effect of quantitative indicators of ilium height on approach of percutaneous endoscopic lumbar discectomy (PELD) treatment in patients with L ₅, S ₁ lumbar disc herniation.

Methods

A retrospective study between May 2014 and March 2016 was conducted, including 100 patients with disc herniation at L ₅, S ₁, who were initially enrolled for the PELD treatment. Among them, 66 patients were successfully treated with PELD (group A), and the other 34 patients failed to perform puncture, catheterization, or microscopical operation due to the influence of iliac bone and other peripheral bone structures and treated with alternative surgical plans. By analyzing the X-ray films of lumbar vertebrae (including bilateral ilium) of the two groups before operation, the concept of ilium height rate and ilium angle rate was put forward innovatively. The ilium height rate and ilium angle rate of the two groups were measured and compared, and the diagnostic critical points of ilium height rate and ilium angle rate were determined by ROC curve analysis.

Results

The ilium height rate was 0.61±0.09, 0.74±0.05 and the ilium angle rate was 0.66±0.08, 0.80±0.08 in groups A and B, respectively, showing significant differences between the two groups ( F=69.729, P=0.000; F=65.165, P=0.000). ROC curve analysis showed that the critical point of ilium height rate was 0.71 (area under ROC curve was 0.927, P=0.000), and the critical point of ilium angle rate was 0.75 (area under ROC curve was 0.965, P=0.000).

Conclusion

PELD is not recommended for patients with L ₅, S ₁ intervertebral disc herniation, when the ilium height rate is greater than 0.71 and/or the ilium angle rate is greater than 0.75. Other surgical plans such as transpedicular approach, transpedicular approach, or open surgery, should be recommended to reduce the risk of surgery and the pain of patients.

Percutaneous Transforaminal Endoscopic Discectomy versus Micro-Endoscopic Discectomy for Lumbar Disc Herniation

BACKGROUND Percutaneous transforaminal endoscopic discectomy (PTED) and micro-endoscopic discectomy (MED) are alternative minimally invasive, widely performed procedures for the treatment of lumbar disc herniation (LDH). This study compared the clinical outcomes of these 2 surgical techniques in treating LDH. MATERIAL AND METHODS A comprehensive literature search was performed in PubMed, MEDLINE, EMBASE, Cochrane, and Google Scholar to identify all relevant studies comparing PTED and MED in treating LDH. RESULTS Eight comparative studies assessing a total of 805 patients were included for the final analysis. The results indicated that PTED needs a shorter incision [-1.02 (-1.21 to -0.83), p<0.001], less time in bed [-2.14 (-3.34 to -0.94), p<0.001], and shorter hospital stay [-1.92 (-2.90 to -0.94), p<0.001], whereas MED is superior regarding intraoperative fluoroscopy [7.47 (2.78 to 12.17), p=0.002] and total cost [0.69 (0.38 to 1.00), p<0.001]. No significant differences were found on operation time, intraoperative blood loss, or complications. Significant lower back pain was found in the PTED group at 1 week postoperatively [-0.52 (-0.95 to -0.10), p=0.02] and 1 year postoperatively or the last follow-up [-0.41 (-0.76 to -0.06), p=0.02]; significant lower leg pain was also detected at 1 week postoperatively [-0.52 (-0.75 to -0.30), p<0.001]. Oswestry Disability Index (ODI) was significant better at 1 week postoperatively in the PTED group [-4.41 (-7.03 to -1.79), p=0.001]. No significant differences were detected at other time points regarding pain score and ODI. CONCLUSIONS Both PTED and MED are safe and effective techniques for treating LDH. However, taking all clinical outcomes together, PTED might be a preferable treatment modality for LDH.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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