Full-endoscopic foraminoplasty for highly down-migrated lumbar disc herniation

Percutaneous endoscopic interlaminar discectomy for high-grade migrated lumbar disc herniation: clinical efficacy and safety assessment

PURPOSE

This study aimed to assess the clinical effectiveness and safety of percutaneous endoscopic interlaminar discectomy (PEID) in the management of high-grade migrated Lumbar disc herniation (LDH).

METHODS

A total of 328 patients who underwent PEID for high-grade migrated LDH between May 2020 and January 2023 in our hospital were selected. Patients were categorized into high-grade migrated group and low-grade migrated group according to preoperative MRI findings. The preoperative and postoperative evaluations of clinical outcomes, such as Visual Analogue Scale (VAS) for lower backs and legs, Oswestry Disability Index (ODI), and modified MacNab criteria for surgical success, were compared between groups.

RESULTS

No statistically significant differences were found in hospitalization time, surgery time, intraoperative hemorrhage, number of intraoperative fluoroscopies, or incision length between the two groups. The lower back and leg VAS scores and ODI exhibited a statistically significant decrease in both groups across all postoperative time intervals. However, the difference between the two groups was not statistically significant. Postoperative nerve root stimulation symptoms were reported in two and three cases in the high-grade migrated group and low-grade migrated group, respectively. One patient in the high-grade migrated group underwent reoperation due to re-herniation at the same segment. There was no significant difference in the rate of excellent-good cases between the two groups, with an overall rate of 94.7%.

CONCLUSION

In treating high-grade migrated disc herniation, PEID offers advantages such as reduced trauma, small incision, quicker recovery and satisfactory clinical safety and efficacy.

Percutaneous Endoscopic Suprapedicular Decompression in the Treatment of Down-Migrated Lumbar DiscHerniation

OBJECTIVE

This study aimed to investigate the clinical efficacy of percutaneous endoscopic suprapedicular decompression in treatment of down-migrated lumbar disc herniation.

METHODS

The clinical data of 43 patients with down-migrated lumbar disc herniation treated with endoscopic surgery at our hospital between January 2022 and January 2023 were retrospectively analyzed. Twenty-two and 21 patients underwent percutaneous endoscopic decompression using the suprapedicular and transforaminal endoscopic surgical system approaches, respectively. The perioperative, follow-up, and imaging data of the groups were compared.

RESULTS

Surgery was uneventful in both groups. The number of intraoperative fluoroscopies and duration of surgery were significantly lower in the suprapedicular group (P < 0.05). The patients in both groups were followed up for at least 12 months. At the last follow-up, lumbar pain and leg pain visual analog scale, Oswestry Disability Index, and 36-Item Short Form Health Survey scores were significantly improved in both groups compared with preoperative values (P < 0.05); the differences in these indexes between the 2 groups were not significant preoperatively (P > 0.05). However, at the last postoperative follow-up, lumbar pain visual analog scale scores were significantly better in the suprapedicular group (0.83 ± 0.85 vs. 2.54 ± 1.32, P < 0.05). There was no significant change in intervertebral space height or lumbar lordotic angle compared with preoperative values in either group at the last follow-up (P > 0.05). However, the spinal canal cross-sectional area significantly increased (P < 0.05).

CONCLUSIONS

The treatment of down-migrated lumbar disc herniation via a suprapedicular approach enabled the incision of the superior margin of the pedicle as needed under direct vision, involved less fluoroscopy while preserving facet joint stability, and enabled targeted removal of the herniated nucleus pulposus, thus greatly reducing residual nucleus pulposus. This surgical procedure was safe, rapid, and showed satisfactory therapeutic efficacy.

Transforaminal endoscopic lumbar discectomy with two-segment foraminoplasty for the treatment of very highly migrated lumbar disc herniation: a retrospective analysis

BACKGROUND

The surgical resection of very highly migrated lumbar disc herniation (VHM-LDH) is technically challenging owing to the absence of technical guidelines. Hence, in the present study, we introduced the transforaminal endoscopic lumbar discectomy (TELD) with two-segment foraminoplasty to manage VHM-LDH and evaluated its radiographic and midterm clinical outcomes.

MATERIALS AND METHODS

The present study is a retrospective analysis of 33 consecutive patients with VHM-LDH who underwent TELD with two-segment foraminoplasty. The foraminoplasty was performed on two adjacent vertebrae on the basis of the migration direction of disc fragments to fully expose the disc fragments and completely decompress the impinged nerve root. The operation duration, blood loss, intra- and postoperative complications, and recurrences were recorded. Additionally, imageological observations were evaluated immediately after the procedure via magnetic resonance image and computerized tomography. Clinical outcomes were evaluated by calculating the visual analog scale (VAS) score and Oswestry Disability Index (ODI). The MacNab criterion was reviewed to assess the patients' opinions on treatment satisfaction. The resection rate of bony structures were quantitatively evaluated on postoperative image. The segmental stability was radiologically evaluated at least a year after the surgery. Additionally, surgery-related and postoperative complications were evaluated.

RESULTS

The average age of the patients was 56.87 ± 7.77 years, with a mean follow-up of 20.95 ± 2.09 months. The pain was relieved in all patients immediately after the surgery. The VAS score and ODI decreased significantly at each postoperative follow-up compared with those observed before the surgery (P < 0.05). The mean operation duration, blood loss, and hospital stay were 56.17 ± 16.21 min, 10.57 ± 6.92 mL, and 3.12 ± 1.23 days, respectively. No residual disc fragments, iatrogenic pedicle fractures, and segmental instability were observed in the postoperative images. For both up- and down- migrated herniation in the upper lumbar region, the upper limit value of resection percentage for the cranial SAP, caudal SAP, and pedicle was 33%, 30%, and 34%, respectively; while those in the lower lumbar region was 42%, 36%, and 46%, respectively. At the last follow-up, the satisfaction rate of the patients regarding the surgery was 97%. Surgery-related complications including dural tear, nerve root injury, epidural hematoma, iatrogenic pedicle fractures, and segmental instability were not observed. One patient (3%) suffered from the recurrence of LDH 10 months after the initial surgery and underwent revision surgery.

CONCLUSIONS

The TELD with two-segment foraminoplasty is safe and effective for VHM-LDH management. Proper patient selection and efficient endoscopic skills are required for applying this technique to obtain satisfactory outcomes.

One-hole split endoscope technique for migrated lumbar disc herniation: a single-centre, retrospective study of a novel technique

BACKGROUND

Lumbar disc herniation (LDH) is one of the most common diseases of the spine, and migrated LDH is a more serious type, associated with nerve root function injury or abnormality. Regarding the increasing surgery adoption of treating migrated LDH, we aimed to investigate the clinical efficacy and safety of discectomy with a novel technique-one-hole split endoscope (OSE) technique.

METHODS

This was a retrospective analysis of migrated LDH treated between December 2020 and September 2021. Hospitalization time, operative duration, intraoperative blood loss, number of fluoroscopy exposures, incision length, postoperative facet preservation rate, number of excellent-good cases, lower back and leg visual analogue score (VAS), Oswestry Disability Index (ODI) and surgical complications were compared between high-grade migration group (82 cases) and low-grade migration group (148 cases). The Macnab criteria was used to evaluate the clinical outcome. The Shapiro‒Wilk test was used to test measurement data, and the χ² test was used to test counting data.

RESULTS

There was no significant difference in hospitalization time, operative duration, intraoperative blood loss, number of fluoroscopy exposures, incision length or postoperative facet preservation rate between the two groups by independent sample t test or nonparametric test. At any time point, the lower back and leg VAS and ODI of the two groups were significantly improved compared to those before the operation, but there was no significant difference between the two groups at the same time point by two-way repeated measures ANOVA. There were two cases of postoperative nerve root stimulation symptoms in the high-grade migration group and three cases in the low-grade migration group. There was one patient reoperated in the high-grade migration group. There was no significant difference in number of excellent-good cases between the two groups. The overall excellent-good rate was 89.6%.

CONCLUSION

The OSE technique has the advantages of less trauma, faster recovery, complete removal of the nucleus pulposus and a satisfactory early clinical efficacy in the treatment of migrated LDH.

Comparison of full-endoscopic foraminoplasty and lumbar discectomy (FEFLD), unilateral biportal endoscopic (UBE) discectomy, and microdiscectomy (MD) for symptomatic lumbar disc herniation

PURPOSE

This study aimed to evaluate the clinical outcomes of full-endoscopic foraminoplasty and lumbar discectomy (FEFLD), unilateral biportal endoscopic (UBE) discectomy, and microdiscectomy (MD) in the treatment of symptomatic lumbar disc herniation (LDH).

METHODS

From January 2020 and May 2021, 128 patients with single-level LDH at L4-5 or L5-S1 received FEFLD, UBE discectomy or MD. Patients were divided into three groups according to surgical method: the FEFLD group (n = 43), the UBE group (n = 42), and the MD group (n = 43). Operative time, fluoroscopy frequency, in-bed time, length of hospital stays, total expenses, complications, visual analogue scale (VAS, 0-10), and Oswestry Disability Index (ODI, 0-100%) were assessed and compared among three groups.

RESULTS

There were no significant differences in VAS or ODI scores at 12 months after surgery among three groups. In comparison with the MD group, the FEFLD and UBE group yield better VAS scores for back pain on the first day following surgery (P < 0.05). The FEFLD group was superior to the UBE group or MD group with less time in bed and shorter hospital stay (P < 0.05). The operation time and total expenses in the UBE group were significantly longer and higher than those in the FEFLD group or MD group (P < 0.05).

CONCLUSIONS

FEFLD and UBE discectomy yield comparable results to conventional MD concerning pain relief and functional outcomes. In addition, FEFLD and UBE discectomy enable less back pain in the immediate postoperative period. FEFLD offers advantages in rapid recovery. Conventional MD is still an efficient and cost-effective surgical procedure.

Current Status and research hotspots in the field of full endoscopic spine surgery: A bibliometric analysis

Purpose

We aimed to comprehensively analyze the current status, hotspots, and trends in full endoscopic spine surgery (FESS) research using bibliometric analysis and knowledge domain mapping.

Methods

The Web of Science database was used to screen FESS-related articles published between January 1, 1993 and June 10, 2022. The evaluation involved the following criteria: total number of articles; H-index; and contributions from countries/regions, institutions, journals, and authors.

Results

A total of 1,064 articles were included. Since 2016, there have been a significant number of publications in the field of FESS. The country/region contributing the largest number of articles was China (37.8%), followed by South Korea (24%), the United States (16.1%), Japan (5.7%), and Germany (5.1%). South Korea (35) had the highest H-index, followed by the United States (27), China (22), Japan (21), and Germany (20). World Neurosurgery (15.7%) published the largest number of FESS-related articles. However, among the top 10 most cited articles, six were published in Spine. The author who contributed the most was S.H. Lee (5.4%), and the largest number of contributions in this field originated from Wooridul Spine Hospital (South Korea; 6.1%). Notably, six of the 10 most published authors in this field were from South Korea. Of the top five productive institutions, three were from South Korea. The keywords with the strongest citation bursts in the field of FESS were “lumbar spine,” “discectomy,” “interlaminar,” “surgical technique,” “follow-up,” “excision,” “thoracic spine,” and “endoscopic surgery.” The 10 clusters generated in this study were: “endoscopic discectomy” (#0), “thoracic myelopathy” (#1), “recurrent lumbar disc herniation” (#2), “low back pain” (#3), “cervical vertebrae” (#4), “lumbar spinal stenosis” (#5), “transforaminal lumbar interbody fusion” (#6), “radiation exposure” (#7), “management” (#8), and “lumbar spine” (#9).

Conclusion

Global research on FESS is mostly concentrated in a few countries/regions and authors. South Korea has made the largest contribution to the field of FESS. Based on the most cited keyword bursts and clusters, the focus of FESS research was found to include its indications, management, and applications.

Knowledge Areas and New Trends in Lumbar Disc Herniation Research: Bibliometrics and Knowledge Mapping Analysis

OBJECTIVE

To determine the coalitions and impact of authors, countries, institutions, and journals, evaluate the knowledge base, find the hotspot trends, and identify the emerging topics in lumbar disc herniation (LDH).

METHOD

The articles related to LDH were obtained from the Web of Science Core Collection on August 21, 2021. Two scientometric software (CiteSpace 5.8.R.1 and VOSviewer 1.6.17) were used to perform bibliometric and knowledge-map analysis.

RESULTS

From the set parameters, 4642 articles were included in the literature. Although the total number of publications fluctuated between 2001 and 2020, a general trend toward increase was observed. Respectively, the most productive country and institution in the field were the United States and Wooridul Spine Hospital. The most active and cited authors were Lee and Weinstein. Spine was the most impactful and cited journal. Weinstein (JAMA 296:2441-2450, 2006) had the highest number of co-citations and Weinstein(N Engl J Med 358:794-810, 2008) had the highest number of citations. The keyword "low back pain" was ranked first for frequency and total link strength, whereas "risk factor" was ranked first for centrality. Topics including pathogenesis (disc herniation), examination methods (MRI), treatment methods (non-surgical treatment, surgical treatment), surgical options (laminectomy, discectomy), clinical observations (double-blind, efficacy, outcome, learning curve), and evaluation of efficacy (meta-analysis) of LDH have been the focus of leading-edge research in 2001-2020.

CONCLUSION

Using bibliometric methods, this study mapped the knowledge map of LDH research in the past 20 years. The study identifies existing trends to provide a framework for further research.