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

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.

Complications in endoscopic spine surgery: a systematic review

PURPOSE

This systematic review aims to investigate the complication rate of endoscopic spine surgeries, stratifying them by technique, district and kind of procedure performed.

METHODS

This study was conducted according to the PRISMA statement. The literature search was conducted in MEDLINE, CINAHL, EMBASE, Cochrane Register, OTseeker and ScienceDirect database. Types of studies included were observational studies (cohort studies, case-control studies and case series) and randomised or quasi-randomised clinical with human subjects. No restrictions on publication year were applied. Repeated articles, reviews, expert's comments, congress abstracts, technical notes and articles not in English were excluded. Several data were extracted from the articles. In particular, data of perioperative (≤ 3 months) and late (> 3 months) complications were collected and grouped according to: (1) surgical technique [uniportal full-endoscopic spine surgery (UESS) or unilateral biportal endoscopic spine surgery (UBESS)]; (2) spinal district treated [cervical, thoracic or lumbar] and (3) type of procedure [discectomy/decompression or fusion]. Complication analysis was performed in subgroups with at least 100 patients to have clinically meaningful statistical validity.

RESULTS

A total of 117 full-text articles were assessed for eligibility. Of the 117 records included, 95 focused their research on UESS (14 LOE V, 33 LOE IV, 43 LOE III and five LOE II) and 23 on UBESS (three LOE V, eight LOE IV, 10 LOE III and two LOE II). A total of 20,020 patients were extracted to investigate the incidence of different perioperative and late complications, 10,405 for UESS and 9615 for UBESS.

CONCLUSION

The present study summarises the complications reported in the literature for spinal endoscopic procedures. On the one hand, the most relevant described were perioperative complications (transient neurological deficit, dural tear and dysesthesia) that are especially meaningful for endoscopic discectomy and decompression. On the other hand, late complications, such as mechanical implant failure, are more common in endoscopic interbody fusion.

LEVEL OF EVIDENCE

I.

Percutaneous Endoscopic Transforaminal Discectomy for the Treatment of Lumbar Disc Herniation with Different Migration Levels: A Retrospective Study

Objective

To investigate the surgical method and efficacy of percutaneous endoscopic transforaminal discectomy (PETD) for the treatment of lumbar disc herniation (LDH) with different migration levels by introducing the strategy of foramenoplasty with the "distal nucleus pulposus as the core".

Methods

Clinical data of LDH patients who underwent single-segment PETD surgery were retrospectively analyzed. Three groups were categorized according to the degree of nucleus pulposus migration in the sagittal position: no migration group, mild migration group, and high migration group. Different sites of foramenoplasty were used for LDH with different degrees of migration. All patients were followed up for at least 12 months. The clinical and follow-up data of the three groups were compared.

Results

A total of 102 patients were included, of which 46 (45.1%) were in the no migration group, 36 (35.3%) in the mild migration group, and 20 (19.6%) in the high migration group. Encouraging treatment results were obtained in all three groups.

Conclusion

PETD is effective in the treatment of LDH with different degrees of migration, and the foramenoplasty concept of "distal nucleus pulposus as the core" can effectively guide the molding site of foramenoplasty and facilitate the accurate placement of the working trocar.

Feasibility of Endoscopic Lumbar Discectomy in a Remote Government Hospital in Thailand: A Cost-Utility Analysis

BACKGROUND

Treatments for lumbar discectomy have developed over time. Recently, endoscopy has played an important role. However, a major obstacle to endoscopy in rural areas is the cost of surgery, particularly for endoscopes and disposable equipment. We assessed the cost effectiveness of endoscopic lumbar discectomy compared to the traditional open microdiscectomy technique in a government hospital in a developing country.

METHODS

This study focused on 50 patients who underwent endoscopic lumbar discectomy between April 2019 and March 2020 at Yala Regional Hospital and were reviewed by our team. The duration of hospital stays, operative time, follow-up, and clinical outcomes at one, three, and six months postoperatively were observed and compared with 30 patients who underwent microscopic lumbar discectomy. Hospital expenses were calculated and compared using t-tests.

RESULTS

Endoscopic discectomy was 4.00 days length of stay while microscopic discectomy has 9.77 days in averages. The pain score was 8.82 for endoscopic surgery and 9.1 for microscopic surgery. The operative price for the endoscopic discectomy was 144.69 USD higher than that for the open lumbar discectomy because of the disposable equipment. However, each patient in the microdiscectomy group had a longer hospital stay and required more perioperative care, which decreased the difference of the total hospital expenses (1,420.612 vs 1,399.16 USD).

CONCLUSION

Full endoscopic lumbar discectomy is an effective procedure that is beneficial for patients. The total hospital costs are not significantly different between the two procedures. To ensure that more patients receive this benefit and to develop surgical competency in government hospitals, the surgical reimbursement fee for endoscopic discectomy should be more affordable than that for conventional discectomy.

Interlaminar Endoscopic Lumbar Discectomy Versus Microscopic Lumbar Discectomy: A Preliminary Analysis of L5-S1 Lumbar Disc Herniation Outcomes in Prospective Randomized Controlled Trials

OBJECTIVE

A preliminary report from a single institution, noninferiority, prospective randomized controlled trial is conducted to determine the effectiveness of interlaminar endoscopic lumbar discectomy (IELD) versus microscopic lumbar discectomy (MLD) for the treatment of L5-S1 lumbar disc herniation (LDH).

METHODS

This prospective, noncrossover, randomized controlled trials was conducted at a single neurosurgical center. Patients with symptomatic radiculopathy or intermittent neurogenic claudication caused by LDH were enrolled from July 2016 to July 2021. The study compared the effectiveness of microscopic and full-endoscopic discectomy procedures. Outcome measures included visual analogue scale (VAS) scores for back and leg pain, Oswestry Disability Index scores, radiologic measurements, endurance time of walking, and satisfaction rate.

RESULTS

Of 37 assessed patients, both IELD and MLD groups demonstrated significant improvements in VAS scores for pain over time, with no significant difference between them. For secondary outcomes, the IELD group had a shorter hospital stay and reduced blood loss but a longer operation time than the MLD group. Radiographic evaluations showed no change compared to preoperative data. Patient satisfaction and recovery rates were slightly higher for the MLD group, but both groups were comparable in most evaluations, with complications being minimal.

CONCLUSION

The IELD was noninferior in improving the intensity of back and leg pain and functional disability, compared to the MLD. Additionally, the IELD showed no difference in clinical outcomes for patients in terms of radiographic results and patient satisfaction rates. The results of this research preliminarily demonstrate that the IELD could be considered an effective alternative to MLD for L5-S1 central or paracentral LDH.

Cost and Effectiveness of Percutaneous Endoscopic Interlaminar Discectomy versus Microscope-Assisted Tubular Discectomy for L5-S1 Lumbar Disc Herniation

OBJECTIVE

To assess the cost and effectiveness of percutaneous endoscopic interlaminar discectomy (PEID) and microscope-assisted tubular discectomy (MATD) for patients with L5/S1 lumbar disc herniation (LDH).

METHODS

The medical and financial records of patients diagnosed with L5/S1 LDH and who underwent either PEID or MATD from April 2021 to April 2022 were retrospectively collected. Demographic and baseline information, perioperative observational index, clinical outcomes, and inpatient costs were analyzed.

RESULTS

Sixty patients were included, with 30 patients in the PEID group and 30 patients in the MATD group. No significant difference was found in demographic and baseline information between the 2 groups (P > 0.05). The PEID group showed significantly shorter incision length, less intraoperative blood loss, shorter hospital stays, and higher intraoperative fluoroscopy frequency compared with the MATD group (P < 0.05). There were no significant differences in visual analog scale back/leg score, Oswestry Disability Index, and 36-Item Short-Form Survey score between PEID and MATD groups before the surgery and at any follow-up time points (P > 0.05). The total cost, surgery cost, and surgical instruments/materials cost were significantly higher in the PEID group compared with the MATD group (P < 0.05). In contrast, the drug and nursing costs were significantly higher in the MATD group than in the PEID group (P < 0.05).

CONCLUSIONS

PEID and MATD provide equivalent clinical efficacy and safety in treating LDH at L5/S1 segment within a 1-year follow-up. However, PEID is less invasive and MATD is less costly. No one surgical technique is superior in all aspects and patients should make decisions according to their top concern.

Minimally invasive endoscopy in spine surgery: where are we now?

INTRODUCTION

Endoscopic spine surgery (ESS) is a minimally invasive surgical technique that offers comparable efficacy and safety with less collateral damage compared to conventional surgery. To achieve clinical success, it is imperative to stay abreast of technological advancements, modern surgical instruments and technique, and updated evidence.

PURPOSES

To provide a comprehensive review and updates of ESS including the nomenclature, technical evolution, bibliometric analysis of evidence, recent changes in the spine communities, the prevailing of biportal endoscopy, and the future of endoscopic spine surgery.

METHODS

We conducted a comprehensive review of the literature on ESS for the mentioned topics from January 1989 to November 2022. Three major electronic databases were searched, including MEDLINE, Scopus, and Embase. Covidence Systematic Review was used to organize the eligible records. Two independent reviewers screened the articles for relevance.

RESULTS

In total, 312 articles were finally included for review. We found various use of nomenclatures in the field of ESS publication. To address this issue, we proposed the use of distinct terms to describe the biportal and uniportal techniques, as well as their specific approaches. In the realm of technical advancement, ESS has rapidly evolved from addressing disc herniation and spinal stenosis to encompassing endoscopic fusion, along with technological innovations such as navigation, robotics, and augmented reality. According to bibliometric analysis, China, South Korea, and the USA have accounted for almost three-quarters of total publications. The studies of the biportal endoscopy are becoming increasingly popular in South Korea where the top ten most-cited articles have been published. The biportal endoscopy technique is relatively simple to adopt, as it relies on a more familiar approach, requires less expensive instruments, has a shorter learning curve, and is also well-suited for interbody fusion. The uniportal approach provided the smallest area of soft tissue dissection. While robotics and augmented reality in ESS are not widely embraced, the use of navigation in ESS is expected to become more streamlined, particularly with the emergence of recent electromagnetic-based navigation technologies.

CONCLUSIONS

In this paper, we provide a comprehensive overview of the evolution of ESS, as well as an updated summary of current trends in the field, including the biportal and uniportal approaches. Additionally, we summarize the nomenclature used in ESS, present a bibliometric analysis of the field, and discuss future directions for the advancement of the field.

Economic comparisons of endoscopic spine surgery: a systematic review

PURPOSE

Full-endoscopic techniques are minimally invasive surgery alternatives to traditional spinal surgery. We performed a systematic review of the literature to assess the costs of these techniques compared to traditional approaches.

METHODS

A systematic review of the literature was performed for economic evaluations that compare endoscopic decompressions of the lumbar spine for stenosis or disc herniation to open or microsurgical decompressions. The search was performed in the following databases: Medline, Embase Classic, Embase, and Central Cochrane library, from January 1, 2005, to October 22, 2022. The included studies were each evaluated according to a formal assessment checklist to evaluate the quality of economic evaluations based on 35 criteria.

RESULT

A total of 1153 studies were identified, with 9 articles included in the final analysis. In evaluating the quality of economic evaluations, the study with the fewest met criteria scored 9/35 and the study with the most met criteria scored 28/35. Only 3 studies completed cost-effectiveness analyses. Surgical procedure duration varied between studies, but hospital length of stays were consistently shorter with endoscopy. While endoscopy was more frequently associated with higher operating costs, studies that measured healthcare and societal costs found endoscopy to be advantageous.

CONCLUSION

Endoscopic spine surgery was found to be cost-effective in treating patients with lumbar stenosis and disc herniation when compared to standard microscopic approaches from a societal perspective. More well-designed economic evaluations investigating the cost-effectiveness of endoscopic spine procedures are needed to further support these findings.

Awake transforaminal endoscopic lumbar discectomy in an ambulatory surgery center: early clinical outcomes and complications of 100 patients

PURPOSE

Transforaminal endoscopic discectomy has been found to have equivalent outcomes to traditional discectomy techniques. Controversy exists concerning whether this should be performed under general anesthetic with neuromonitoring or can be safely performed on awake patients without neuromonitoring. This study aimed to evaluate the safety and effectiveness of awake transforaminal endoscopic discectomy in an ambulatory setting.

METHODS

100 consecutive patients with lumbar disc herniations treated with transforaminal endoscopic discectomy by a single surgeon were enrolled in the study. All procedures were performed under conscious sedation with local anesthetic. Preoperative and postoperative visual analog scale (VAS) scores were recorded and compared. Time spent in recovery prior to discharge home and complications were also recorded.

RESULTS

Average VAS score improved from a mean of 6.85 to 0.74 (median 7 to 0) immediately postoperatively. The average time spent in Post Anesthesia Care Unit (PACU) prior to discharge was 56.7 min. Average VAS score at 2 weeks was 3.07 (median 2.5). Complication rates were commensurate with published results in the literature. The most common complication was radiculitis, which appears to be more likely with foraminal/extraforaminal herniations at a rate of 20.7%, versus 2.6% for central/paracentral herniations. There were no cases that required conversion to general anesthetic or transfer to a hospital and no permanent nerve injuries in this cohort.

CONCLUSIONS

Endoscopic discectomy can safely and successfully be performed in an ambulatory surgery center under conscious sedation and local anesthetic without neuromonitoring. This procedure leads to rapid recovery in the PACU and significantly improved VAS scores postoperatively.

LEVEL OF EVIDENCE

Level IV.

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.

The Role and Clinical Outcomes of Endoscopic Spine Surgery of Treating Spinal Metastases; Outcomes of 29 Cases From 8 Countries

OBJECTIVE

We aim to report the outcomes and feasibility of endoscopic spine surgery used to treat symptomatic spinal metastases patients. This is the most extensive series of spinal metastases patients who underwent endoscopic spine surgery.

METHODS

A worldwide collaborative network group of endoscopic spine surgeons, named 'ESSSORG,' was established. Patients diagnosed with spinal metastases who underwent endoscopic spine surgery from 2012 to 2022 were retrospectively reviewed. All related patient data and clinical outcomes were gathered and analyzed before the surgery and the followtime period of 2 weeks, 1 month, 3 months, and 6 months.

RESULTS

A total of 29 patients from South Korea, Thailand, Taiwan, Mexico, Brazil, Argentina, Chile, and India, were included. The mean age was 59.59 years, and 11 of them were female. The total number of decompressed levels was 40. The technique was relatively equal (15 uniportal; 14 biportal). The average length of admission was 4.41 days. Of all patients with an American Spinal Injury Association Impairment Scale of D or lower before surgery, 62.06% reported having at least one recovery grade after the surgery. Almost all clinical outcomes parameters statistically significantly improved and maintained from 2 weeks to 6 months after the surgery. Few surgical-related complications (4 cases) were reported.

CONCLUSION

Endoscopic spine surgery is a valid option for treating spinal metastases patients as it could yield comparable results to other minimally invasive spine surgery techniques. As the aim is to improve the quality of life, this procedure is valuable and holds value in palliative oncologic spine surgery.

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.

Transforaminal Versus Interlaminar Endoscopic Lumbar Discectomy for Lumbar Disc Herniation: A Systematic Review and Meta-Analysis

STUDY DESIGN

Meta-analysis and systematic review.

OBJECTIVE

This study aims to investigate and compare patient-reported outcomes, perioperative data, and complications between 2 common endoscopic approaches for lumbar disc herniation: transforaminal and interlaminar endoscopic lumbar discectomy, by published high-quality evidence.

METHODS

Electronic databases were searched for reported outcomes following TELD and IELD. Oswestry Disability Index (ODI), visual analog scale of back (VASB) and leg pain (VASL), and MacNab criteria were evaluated. Operative time, hospital stays, blood loss, radiation exposure, and complications were investigated. Odds ratio (OR) and mean differences (MD) with 95% confidence intervals (CI) were calculated using random and fixed-effect models.

RESULTS

Total of 1948 patients from 18 studies were included, consisting of 1006 patients (51.6%) in TELD group and 942 (48.4%) patients in IELD group. TELD had better improvement of postoperative ODI (MD = 1.26; 95% CI: .07-2.16; P = .04), postoperative VASB (MD = -.23; 95% CI: -.40 to -.05; P = .01) and last follow-up VASB (MD = -.25; 95% CI: -.41 to -.09; P = .002), but with longer operative time (MD = 10.1 min; 95% CI: 1.925-18.77; P < .00001) and more fluoroscopic time (SMD = 4.12; 95% CI: 3.22-5.03; P < .00001), especially in L5-S1 operation. Bed rest time was significantly longer following IELD, with no difference in VASL, hospital stays, or complication.

CONCLUSION

We found comparable clinical outcomes in terms of ODI, VAS, patient satisfaction, hospital stays, and complication between both techniques. TELD required more radiation exposure and longer operative time at L5-S1 level than IELD. Our study provided results to help consider appropriate approaches for selected patients and informed consent of benefits from each approach.

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.

Clinical comparison of percutaneous transforaminal endoscopic discectomy and unilateral biportal endoscopic discectomy for single-level lumbar disc herniation

Purpose

To compare the clinical outcomes of percutaneous transforaminal endoscopic discectomy (PTED) and unilateral biportal endoscopic discectomy (UBE) for the treatment of single-level lumbar disc herniation (LDH).

Materials and methods

From January 2020 to November 2021, 62 patients with single-level LDH were retrospectively reviewed. All patients underwent spinal surgeries at the Affiliated Hospital of Chengde Medical University and Beijing Tongren Hospital, Capital Medical University. Among them, 30 patients were treated with UBE, and 32 were treated with PTED. The patients were followed up for at least one year. Patient demographics and perioperative outcomes were reviewed before and after surgery. The Oswestry Disability Index (ODI), visual analog scale (VAS) for back pain and leg pain, and modified MacNab criteria were used to evaluate the clinical outcomes. x-ray examinations were performed one year after surgery to assess the stability of the lumbar spine.

Results

The mean ages in the UBE and PTED groups were 46.7 years and 48.0 years, respectively. Compared to the UBE group, the PTED group had better VAS scores for back pain at 1 and 7 days after surgery (3.06 ± 0.80 vs. 4.03 ± 0.81, P < 0.05; 2.81 ± 0.60 vs. 3.70 ± 0.79, P < 0.05). The UBE and PTED groups demonstrated significant improvements in the VAS score for leg pain and ODI score, and no significant differences were found between the groups at any time after the first month (P > 0.05). Although the good-to-excellent rate of the modified MacNab criteria in the UBE group was similar to that in the PTED group (86.7% vs. 87.5%, P > 0.05), PTED was advantageous in terms of the operation time, estimated blood loss, incision length, and length of postoperative hospital stay.

Conclusions

Both UBE and PTED have favorable outcomes in patients with single-level LDH. However, PTED is superior to UBE in terms of short-term postoperative back pain relief and perioperative quality of life.

Comparison of percutaneous transforaminal endoscopic discectomy and open lumbar discectomy for lumbar disc herniations: A systematic review and meta-analysis

Purpose

In order to compare the outcomes of percutaneous transforaminal endoscopic discectomy (PTED) and open lumbar discectomy (OLD) for lumbar disc herniation (LDH).

Methods

The Pubmed, Cochrane Library, Web of Sience, Embase, Clinicaltrials.gov, CBM, CNKI, VIP, Wangfang databases were searched from inception to April 30, 2022 to collect the published studies about PTED vs. OLD for treatment of LDH. The Revman 5.2 was used for data analysis. The primary outcomes were excellent rates, complication rates and reoperation rates. The secondary outcomes were length of incision, length of operation, length of hospital stay, and the amount of intraoperative blood loss.

Results

A total of nine studies were included, of which, eight randomized controlled trials and one retrospective study involving 1,679 patients with LDH (755 patients for PTED, and 924 patients for OLD) were included. According to meta-analysis, there were no significant difference in excellent rates (odds ratio [OR] = 1.47, 95% confidence intervals [CI]: 0.94–2.28, P = 0.09), reoperation rates (OR = 0.96, 95% CI: 0.50–1.84, P = 0.90), length of operation [standardized mean differences (SMD) = −17.97, 95%CI: −54.83–18.89, P = 0.34], and the amount of intraoperative blood loss (SMD = −128.05, 95%CI: −258.67–2.57, P = 0.05), respectively. There were significant differences in complication rates (OR = 0.22, 95% CI: 0.14–0.33, P < 0.001), length of incision (SMD = −2.76, 95%CI: −2.88–−2.65, P < 0.001), and length of hospital stay (SMD = −5.19, 95%CI: −5.36–−5.01, P < 0.001), respectively.

Conclusions

PTED can achieve better outcomes with respect to the complication rates, length of incision, and length of hospital stay compared with OLD.

Clinical Features and Management of Seizure After Percutaneous Endoscopic Spine Surgery: A Retrospective Case Series Analysis

OBJECTIVE

To describe the perioperative clinical features, management, and outcomes of patients with seizure after percutaneous endoscopic spine surgery (PESS).

METHODS

Patients who experienced seizure after PESS in a tertiary orthopedic hospital between January 2016 and June 2022 were retrospectively recruited, and patient charts were reviewed.

RESULTS

Twenty-nine patients were recruited, and the incidence of seizure after PESS was 0.52%. The operation time was 110.0 minutes (interquartile range [IQR], 82.5-235.0 minutes) and the irrigation speed was 109.0 mL/minute (IQR, 86.5-145.5 mL/minute). Definitive dural tears were reported in 15 patients (51.7%). In addition to agitation and myotonia, significant increased respiratory rate (29.9 ± 6.5 breaths/minute), tachycardia (112.1 ± 20.6 beats/minute), and hypertension (systolic, 189.5 ± 21.9 mm Hg; diastolic, 98.3 ± 10.6 mm Hg) were observed. Arterial blood gas analysis showed hypocapnia, metabolic acidosis, and hyperlactatemia. All patients received analgesia and sedation as well as hyperosmolar therapy. The estimated duration of seizure was 3.0 hours (IQR, 2.5-4.0 hours) and the postoperative length of hospital stay was 3.0 (IQR, 3.0-5.5) days. The Japanese Orthopaedic Association score and visual analog scale score improved markedly within 6 months after surgery.

CONCLUSIONS

Despite the low incidence and short duration, seizure after PESS should be considered a critical and urgent syndrome. Management strategies for seizure mainly involve intensive care, securing the airway, analgesia and sedation, hyperosmolar therapy, and negative fluid balance. No significant adverse effects of seizure on clinical outcomes were observed during 6 months of follow-up.

Short-Term Postoperative Pain and Function of Unilateral Biportal Endoscopic Discectomy versus Percutaneous Endoscopic Lumbar Discectomy for Single-Segment Lumbar Disc Herniation: A Systematic Review and Meta-analysis

Objective

Spinal surgery is gradually moving toward minimally invasive surgery, but there is still some lack of knowledge about the Unilateral Biportal Endoscopic (UBE) technique that has been hotly debated in recent years. We performed this systematic review and meta-analysis to clarify whether UBE is superior to percutaneous endoscopic lumbar discectomy (PELD) for relieving short-term postoperative pain and promoting functional recovery.

Methods

Computer searches of PubMed, Embase, Cochrane Library, Web of Science, CNKI, and Wanfang databases were performed to search for studies on UBE versus PELD for single-segment lumbar disc herniation (ssLDH) from the time of database construction to Mar. 2022, and two investigators independently performed literature screening and data extraction, and evaluation of the quality of the included studies was observed as operation time, complications, and visual analogue scale (VAS) at each preoperative and postoperative stage as well as Oswestry Disability Index (ODI), and meta-analysis was performed by applying the Review Manager 5.4 software.

Results

Meta-analysis showed that PELD had shorter operation time (MD = 35.36, 95% CI (4.67, 66.04), P = 0.02) and had lower VAS of back pain at 3 days postoperatively (MD = 0.62, 95% CI (0.04, 1.19), P = 0.04) compared to the UBE. However, there was no statistical significance between the two groups in terms of complications (MD = 2.53, 95% CI (0.40, 16.11), P = 0.33), VAS of back pain at 30 days postoperatively (MD = 0.05, 95% CI (-0.19, 0.28), P = 0.70), VAS of leg pain at 3 days postoperatively (MD = 0.21, 95% CI (-0.20, 0.61), P = 0.33), VAS of leg pain at 30 days postoperatively (MD = 0.09, 95% CI (-0.29, 0.46), P = 0.65), and ODI at 30 days postoperatively (MD = -0.81, 95% CI (-3.03, 1.41), P = 0.47).

Conclusions

Current evidence suggests that both UBE and PELD are effective in relieving short-term postoperative pain and promoting functional recovery, and there is no difference in complications between them; UBE requires longer operation time, and PELD may be superior in relieving immediate postoperative pain. This trial is registered with PROSPERO ID: CRD42021287810.

Risk Factors for Poor Outcomes Following Minimally Invasive Discectomy: A Post Hoc Subgroup Analysis of 2-Year Follow-up Prospective Data

Objective

A post hoc subgroup analysis of prospectively collected data from a randomized controlled trial was conducted to identify risk factors related to poor outcomes in patients who underwent minimally invasive discectomy.

Methods

Patients were divided into satisfied and dissatisfied subgroups based on Oswestry Disability Index (ODI), visual analogue scale (VAS) back pain score (VAS-back) and leg pain score (VAS-leg) at short-term and midterm follow-up according to the patient acceptable symptom state threshold. Demographic characteristics, radiographic parameters, and clinical outcomes between the satisfied and dissatisfied subgroups were compared using univariate and multivariate analysis.

Results

A total of 222 patients (92.1%) completed 2-year follow-up, and the postoperative ODI, VAS-back, and VAS-leg were significantly improved after surgery as compared to preoperatively. Multivariate analysis indicated older age (p=0.026), lateral recess stenosis (p=0.046), and lower baseline ODI (p=0.027) were related to poor short-term functional improvement. Higher baseline VAS-back (p=0.048) was associated with poor short-term relief of back pain, while absence of decreased sensation (p=0.019) and far-lateral disc herniation (p=0.004) were associated with poorer short-term relief of leg pain. Lumbar facet joint osteoarthritis was identified as a risk factor for poor functional improvement (p=0.003) and relief of back pain (p=0.031). Disc protrusion (p=0.036) predicted poorer relief of back pain at midterm follow-up.

Conclusion

In this study, several factors were identified to be predictive of poor surgical outcomes following minimally invasive discectomy. (ClinicalTrials.gov number: NCT01997086).

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).