Comparison of the Safety and Effectiveness of Percutaneous Endoscopic Lumbar Discectomy for Treating Lumbar Disc Herniation Under Epidural Anesthesia and General Anesthesia

Immediate fever during anaesthesia recovery after surgical procedure with scoliosis: A case report and literature review

INTRODUCTION AND IMPORTANCE

Fever is a common clinical symptom in patients with postoperative scoliosis. However, there are rare reports of immediately fevers occurring following operative procedures.

CASE PRESENTATION

A 15-year-old female with a 1-year history of scoliosis was admitted to the hospital after a health examination. The patient was diagnosed with idiopathic scoliosis and underwent a posterior idiopathic scoliosis procedure and correction for pedicle fixation. The clinical symptoms, including chills, fever, increased heart rate and increased blood pressure, were observed immediately following surgery during anaesthesia recovery. The patient was discharged from the hospital 12 days post-surgery. Over the 90-day follow-up, no chills, fever (≥38 °C), deep tissue infection, or surgery-related complications were reported. This remained consistent for the subsequent 3-year follow-up.

CLINICAL DISCUSSION

The patient was discharged 12 days after the operation, and no chills or fever (≥38 °C) occurred during the 90-day follow-up. Furthermore, there were no instances of deep tissue infection or any other surgery-related complications throughout the subsequent 3-year follow-up duration. A literature review has performed for this subject by systematic review. We identified only three reports that specifically examined postoperative fever as an observational measure among spine surgical patients. Unfortunately, none of these reports mentioned immediate postoperative fever.

CONCLUSION

Based on the available clinical data and research evidence, it is recommended to exercise caution when treating patients who experience postoperative chill and fever, as it may be caused by a combination of intraoperative hypothermia and anaesthesia inhibition. While these symptoms may be self-limiting in nature, close monitoring and appropriate management should be implemented to ensure patient safety and to identify any potential complications.

Comparison of different concentrations of ropivacaine in epidural anesthesia for percutaneous transforaminal endoscopic discectomy: a randomized controlled trial

BACKGROUND

This study investigated the optimal concentration of ropivacaine epidural anesthesia for clinical use in percutaneous transforaminal endoscopic discectomy (PTED) by comparing the effects of different concentrations.

METHODS

Seventy patients scheduled for their first PTED procedure were enrolled in this randomized controlled trial. Patients were randomized to receive ropivacaine at varying concentrations (0.3% or 0.4%). Primary outcome measures included the numeric rating scale (NRS) and hip extension level (HEL). Secondary outcome measures included intraoperative fentanyl dosage and postoperative complications.

RESULTS

One patient withdrew due to severe postoperative complications. The remaining 69 patients were allocated to the 0.3% (n = 34) and 0.4% (n = 35) groups, respectively. Baseline characteristics showed no significant differences between the two groups (P > 0.05). The NRS score was significantly lower in the 0.4% group than in the 0.3% group (P < 0.01), whereas the HEL score was significantly higher (P < 0.001). The average fentanyl dose in the 0.4% group was significantly lower than that in the 0.3% group (P < 0.01). Postoperative complications occurred in five and two patients in the 0.3% and 0.4% groups, respectively.

CONCLUSION

Although 0.4% ropivacaine (20 mL) impacts muscle strength, it does not impede PTED surgery. Given its effective analgesic properties and few postoperative complications, 0.4% ropivacaine can be considered a preferred dose for PTED.

TRIAL REGISTRATION

This study was registered with the Chinese Clinical Trials Registry (Registration number: ChiCTR2200060364; Registration Date: 29/5/2022) and on chictr.org.cn ( https://www.chictr.org.cn/showproj.html?proj=171002 ).

Determining the Maximum Tolerable Concentration of Ropivacaine to Maintain Sensation of the Nerve Root in Percutaneous Endoscopic Transforaminal Lumbar Discectomy: Can Epidural Anaesthesia Achieve Pain-Tactile Separation Block to Avoid Nerve Injury?

Introduction

Nerve injury is a serious complication of percutaneous endoscopic transforaminal lumbar discectomy due to nerve root contact. The maximum tolerable concentration (MTC) of ropivacaine concentration for epidural anaesthesia, is defined as the concentration that minimises pain while preserving the sensation of the nerve roots. This distinct advantage allows the patient to provide feedback to the surgeon when the nerve roots are contacted.

Methods

We used a biased-coin design to determine the MTC, which was estimated by the 10% effective concentration (EC10), ie, the concentration at which 10% of patients lost sensation in the nerve roots. The determinant for positive response was lack of sensory feedback upon contact with the nerve root, and the feedback from occurrence of sensations in the innervation area upon contact with the nerve root was defined as a negative response. Primary outcome was the response from contact nerve root. Secondary outcomes were the type and number of statements of negative response and each patient's pain score during surgery.

Results

Fifty-four patients were included in this study. The EC10 was 0.434% (95% CI: 0.410%, 0.440%) using isotonic regression in comparison with 0.431% (95% CI: 0.399%, 0.444%) using probit regression. Three type statements of negative response were reported including "tactile sensation", radiculalgia, and numbness.

Conclusion

The MTC of ropivacaine used for epidural anaesthesia was 0.434% to avoid nerve injury in percutaneous endoscopic transforaminal lumbar discectomy.

Predictive Factors for Residual Low Back Pain Following Percutaneous Endoscopic Lumbar Discectomy in Patients with Lumbar Disc Herniation

BACKGROUND Percutaneous endoscopic lumbar discectomy (PELD) is a mature and popular surgery for treatment of lumbar disc herniation (LDH). The main objective of our study was to identify risk factors for residual low back pain after PELD and to improve postoperative management. MATERIAL AND METHODS We retrospectively analyzed the clinical and imaging data of 251 patients who underwent PELD for LDH. We defined residual LBP as visual analog scale (VAS) score for LBP ≥3 at 2 years postoperatively, and severe LBP was defined as VAS for LBP ≥7.5. The clinical and imaging data were analyzed by comparing patients with VAS scores ≥3 and <3, and univariate analysis and multivariable logistic regression analysis were applied to predict the risk factors for residual LBP. RESULTS There were 56 (22.3%) patients with LBP VAS ≥3 at 2 years postoperatively. Multivariable logistic regression analysis demonstrated that severe baseline VAS for LBP (P<0.001), MCs type I (P=0.006), and severe fatty infiltration of the paravertebral muscles (P<0.001) were independent risk factors for residual LBP after PELD. CONCLUSIONS In patients with LDH, MCs type I, severe baseline LBP, and fatty infiltration of the paravertebral muscles were predictive factors for residual LBP after PELD. Our study suggests that spine surgeons should pay more attention to these imaging parameters, which may be a helpful indicator for the choice of surgical modality.

Ultrasound-guided erector spinae plane block for awake spine surgery: A case report and review of the literature

Percutaneous endoscopic lumbar discectomy is increasingly gaining recognition as an alternative to open microdiscectomy for the treatment of intervertebral disk herniation. Apart from the neuraxial blockade, and general anesthesia, there is literature demonstrating the performance of endoscopic lumbar discectomy under sole local anesthesia infiltration. This is particularly advantageous as an awake patient assists the surgeon by verbalizing and preventing any inadvertent nerve root damage. However, marked pain has been reported during key steps such as endoscope port installation and radiculolysis. The erector spinae plane (ESP) block is an interfascial paraspinal block that soaks the spinal nerve roots with epidural spread providing superior analgesia for endoscopic discectomy. The utility of ESP block as a perioperative analgesic technique following spine surgery is well established; there are no reports of successful endoscopic discectomy performed using this block. This article emphasizes the utility of ESP block as the sole anesthetic technique for minimally invasive spine surgery in the awake state.

Clinical Outcomes of Percutaneous Endoscopic Interlaminar Discectomy Using a Laminotomy Technique With Modified Stepwise Local Anesthesia

BACKGROUND

Percutaneous endoscopic interlaminar discectomy (PEID) has been widely used in minimally invasive treatment of lumbar disc herniation (LDH) but is difficult to perform because of the narrow interlaminar window and painful for the patient. Therefore, further research is needed to find a safe and effective method to facilitate the development of PEID.

METHODS

Seventy-one consecutive patients with LDH who underwent PEID using a laminotomy technique with modified stepwise local anesthesia between July 2017 and June 2020. All patients were followed up for at least 6 months. Preoperative patient demographics, perioperative outcomes, and clinical outcomes were recorded. Visual Analog Scale (VAS) scores, Oswestry Disability Index (ODI) scores, and Macnab criteria were used to assess clinical results.

RESULTS

All patients underwent successful surgery under local anesthesia with no conversions to open surgery. The mean operation time was 79.56 ± 32.78 minutes and the average hospital stay was 6.44 ± 2.98 nights. Before surgery, the mean VAS score was 5.66 ± 1.206 and the mean ODI score was 68.41 ± 6.634; the respective scores were decreased to 0.65 ± 0.635 and 7.06 ± 1.594 after 4 weeks of follow-up (P < 0.001) and to 0.56 ± 0.691 and 7.11 ± 0.176 after 6 months (P < 0.001). According to the MacNab criteria, the outcome was excellent in 60 cases and good in the remaining 11 cases.

CONCLUSIONS

PEID via a laminotomy technique with stepwise local anesthesia is safe and effective for L4-5 and L5-S1 LDH.

Comparative analysis of perioperative characteristics and early outcomes in transforaminal endoscopic lumbar diskectomy: general anesthesia versus conscious sedation

PURPOSE

To better understand how anesthesia type impacts patient selection and recovery in TELD, we conducted a multicenter prospective study which evaluates the differences in perioperative characteristics and outcomes between patients who underwent TELD with either general anesthesia (GA) or conscious sedation (CS).

METHODS

We prospectively collected data from all TELD performed by five neurosurgeons at five different medical centers between February and October of 2022. The study population was dichotomized by anesthesia scheme, creating CS and GA cohorts. This study's primary outcomes were the Oswetry Disability Index (ODI) and the Visual Analog Scale (VAS) for back and leg pain, assessed preoperatively and at 2-week follow-up.

RESULTS

A total of 52 patients underwent TELD for symptomatic lumbar disk herniation. Twenty-three patients received conscious sedation with local anesthesia, and 29 patients were operated on under general anesthesia. Patients who received CS were significantly older (60.0 vs. 46.7, p < 0.001) and had lower BMI (28.2 vs. 33.4, p = 0.005) than patients under GA. No intraoperative or anesthetic complications occurred in the CS and GA cohorts. Improvement at 2-week follow-up in ODI, VAS-back, and VAS-leg was greater in patients receiving CS relative to patients under GA, but these differences were not statistically significant.

CONCLUSION

In our multicenter prospective analysis of 52 patients undergoing TELD, we found that patients receiving CS were significantly older and had significantly lower BMI compared to patients under GA. On subgroup analysis, no statistically significant differences were found in the improvement of PROMs between patients in the CS and GA group.

General vs Local Anesthesia for Percutaneous Endoscopic Lumbar Discectomy (PELD): A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review.

OBJECTIVES

It remains unknown whether general anesthesia (GA) or local ± epidural anesthesia (LA) results in superior outcomes with percutaneous endoscopic lumbar discectomy (PELD). The present study sought to examine the impact of anesthesia type on patient-reported outcomes (PROs) and complications with PELD.

METHODS

Systematic review and meta-analysis examining PELD performed under GA or LA was conducted. Patient-reported outcomes including Visual Analog Scale (VAS)-leg/back, and Oswestry Disability Index (ODI) scores were collected. Complication, recurrent disc herniation, durotomy, and reoperation rates as well as surgical data were recorded. All outcomes were compared between pooled studies examining GA or LA.

RESULTS

Sixty-eight studies consisting of 5269 patients (724 GA, 4465 LA) were included in the meta-analysis. Overall complication rate was significantly higher in the GA group (9% vs 4%, P = .003). Durotomy rates, length of stay, recurrent disc herniation and reoperation rates were similar between groups. At the first follow-up timepoint, the LA group demonstrated significant improvements in VAS back and ODI scores (P < .05) while the GA group did not (P > .05). At the final follow-up (> 6 months), the percent of patients achieving an excellent McNab score was significantly higher in the GA vs LA group (P < .001).

CONCLUSIONS

Percutaneous endoscopic lumbar discectomy with LA may be associated with greater short-term improvement in VAS back pain and ODI scores. General anesthesia may be associated with more durable pain relief but a higher complication rate. Further systematic investigation is necessary to determine what short and long term benefits are associated with PELD performed under LA and GA.

Cost-utility analysis of endoscopic lumbar discectomy following a uniform clinical pathway in the Korean national health insurance system

INTRODUCTION

Full-endoscopic lumbar discectomy (FELD) is a type of minimally invasive spinal surgery for lumbar disc herniation (LDH). Sufficient evidence exists to recommend FELD as an alternative to standard open microdiscectomy, and some patients prefer FELD due to its minimally invasive nature. However, in the Republic of Korea, the National Health Insurance System (NHIS) controls the reimbursement and use of supplies for FELD, but FELD is not currently reimbursed by the NHIS. Nonetheless, FELD has been performed upon patients' request, but providing FELD for patients' sake is inherently an unstable arrangement in the absence of a practical reimbursement system. The purpose of this study was to conduct a cost-utility analysis of FELD to suggest appropriate reimbursements.

METHOD

This study was a subgroup analysis of prospectively collected data including 28 patients who underwent FELD. All patients were NHIS beneficiaries and followed a uniform clinical pathway. Quality-adjusted life years (QALYs) were assessed with a utility score using the EuroQol 5-Dimension (EQ-5D) instrument. The costs included direct medical costs incurred at the hospital for 2 years and the price of the electrode ($700), although it was not reimbursed. The costs and QALYs gained were used to calculate the cost per QALY gained.

RESULT

Patients' mean age was 43 years and one-third (32%) were women. L4-5 was the most common surgical level (20/28, 71%) and extrusion was the most common type of LDH (14, 50%). Half of the patients (15, 54%) had jobs with an intermediate level of activity. The preoperative EQ-5D utility score was 0.48±0.19. Pain, disability, and the utility score significantly improved starting 1 month postoperatively. The average EQ-5D utility score during 2 years after FELD was estimated as 0.81 (95% CI: 0.78-0.85). For 2 years, the mean direct costs were $3,459 and the cost per QALY gained was $5,241.

CONCLUSION

The cost-utility analysis showed a quite reasonable cost per QALY gained for FELD. A comprehensive range of surgical options should be provided to patients, for which a practical reimbursement system is a prerequisite.

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.

Assessing the Learning Process of Transforaminal Endoscopic Discectomy for Sciatica

OBJECTIVE

Percutaneous transforaminal endoscopic discectomy (PTED) is gaining popularity by both surgeons and patients as a less invasive treatment option for sciatica. Concerns, however, exist for its learning curve. No previous study has assessed the learning process of PTED. Hereby we present the learning process of 3 surgeons learning PTED.

METHODS

This analysis was conducted alongside a multicenter randomized controlled trial. After attending a cadaveric workshop, 3 spine-dedicated surgeons started performing PTED, initially under the supervision of a senior surgeon. After each 5 cases, and up to case 20, the learning process was evaluated using the validated questionnaires (objective structured assessment of technical skills [OSATS], global operative assessment of laparoscopic skills [GOALS]) and a 10-step checklist specifically developed for PTED.

RESULTS

In total, 3 learning curve surgeons performed a total of 161 cases. Based on self-assessment, surgeons improved mostly in the domains "time and motion," "respect for tissue," and "knowledge and handling of instruments." Learning curve surgeons were more able to detect differences in performances on the OSATS than the senior surgeon. Based on the GOALS, the biggest improvements could be seen in "depth-perception" and "autonomy." Based on the 10-item specific checklist, all surgeons performed all 10 steps by case 10, while only 1 surgeon performed all steps adequately by case 15.

CONCLUSION

Based on these study results, PTED appears to be successfully adopted stepwise by 3 spine-dedicated surgeons. From 15 cases on, most steps are performed adequately. However, more cases might be necessary to achieve good clinical results. Validated tools are needed to determine the cutoff when a surgeon should be able to perform PTED independently.

Effect of dexmedetomidine administration on analgesic, respiration and inflammatory responses in patients undergoing percutaneous endoscopic lumbar discectomy: a prospective observational study

Background

Local anesthesia has been recommended for percutaneous endoscopic lumbar discectomy (PELD) in recent years; however, the efficacy, including oxidative stress, inflammatory reactions and ventilation effects, when intravenous dexmedetomidine (DEX) is administered during PELD has not been described.

Methods

Sixty adult patients undergoing PELD were randomly allocated to either an intravenous DEX sedation group (Group A) or a normal saline group (Group B). Respiratory data, including minute ventilation (MV), tidal volume (TV), and respiratory rate (RR), were recorded using a respiratory volume monitor (RVM), and peripheral oxygen saturation (SpO₂) was monitored by pulse oximetry. The visual analog score (VAS) was used to assess the level of pain. The serum levels of inflammatory biomarkers including interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) were to assess inflammatory reactions. The serum levels of oxidative stress biomarkers including malondialdehyde (MDA) and glutathione peroxidase (GSH-PX) were also recorded to evaluate oxidative stress.

Results

There were no significant differences in RR, MV, TV and SpO₂ between the two groups at any time point (P > 0.05). Group B exhibited lower serum levels of GSH-PX (P < 0.0001) and higher serum levels of MDA (p < 0.0001) than Group A at the end of surgery. Twenty-four hours after surgery, Group B exhibited higher serum levels of IL-6 (P = 0.0033), TNF-α (P = 0.0002), and MDA (P < 0.0001) and lower serum levels of GSH-PX (P < 0.0001) than Group A. In addition, Group A exhibited lower VAS (P < 0.0001) than Group B during surgery.

Conclusions

DEX administration using RVM not only provides analgesia without ventilatory depression but also alleviates oxidative stress and inflammatory reactions in patients undergoing PELD.

Determining the Minimum Effective Concentration of Ropivacaine in Epidural Anesthesia for Tolerable Pain in Transforaminal Percutaneous Endoscopic Lumbar Discectomy to Avoid Nerve Injury: A Double-Blind Study Using a Biased-Coin Design

Purpose

Epidural anesthesia (EA) is the main anesthesia method for transforaminal percutaneous endoscopic lumbar discectomy (PELD). Reducing the concentration of ropivacaine can help preserve tactile sensation, allowing patients to provide timely feedback to the surgeons when a nerve root is contacted to avoid nerve injury. Therefore, a 90% effective concentration (EC₉₀) that allows for mild pain [visual analog scale (VAS) score ≤3] while maximizing tactile sensation must be identified.

Methods

The concentration of ropivacaine for EA was varied for consecutive patients in this study using a two-stage biased-coin design (BCD) according to the response of the previous patient; the concentration used for the first patient was 0.2%. When the previous patient had a negative response (VAS score >3), the concentration used for the next one was increased by 0.015%. When the previous patient had a positive response (VAS score ≤3), the concentration used for the next one had an 89% probability of remaining the same and an 11% probability of being reduced by 0.015%. The EC₉₀ of ropivacaine was estimated using isotonic regression, and the 95% confidence interval (CI) was estimated using the bootstrapping method in R.

Results

A total of 58 patients were included in the study. The calculated EC₉₀ was 0.294% [95% CI (0.271%, 0.303%)]. Among 13 patients who reported unintended nerve root contact during the operation, none were found to have irreversible nerve injury after the operation.

Conclusion

To preserve maximum tactile sensation, the EC₉₀ of ropivacaine was 0.294% for patients with allowed mild pain. This concentration could allow for timely feedback when the nerve root is contacted, to avoid nerve injury.

The Comparison of Fluoroscopy-Guided Epidural Anesthesia with Conscious Sedation and General Anesthesia for Endoscopic Lumbar Decompression Surgery: A Retrospective Analysis

BACKGROUND

With advances and refinements in endoscopic lumbar spine surgery showing effective and satisfactory results, the need for simple yet effective anesthetic techniques for minimally invasive endoscopic spine surgery has increased. The aim of this study was to compare feasibility and postoperative outcomes of fluoroscopy-guided epidural anesthesia with general anesthesia in patients undergoing endoscopic lumbar decompression surgery (≤3 levels).

METHODS

Patients who underwent 1-3 levels of endoscopic lumbar decompression surgery under either fluoroscopy-guided epidural or general anesthesia between January 2019 and October 2020 were retrospectively reviewed. Postoperative pain intensity and use of rescue analgesics for up to 48 hours were compared between the epidural and general anesthesia groups. Intraoperative anesthetic data and postoperative recovery profiles were also analyzed.

RESULTS

Postoperative pain scores were significantly lower in the epidural anesthesia group compared with the general anesthesia group at 10 minutes after recovery room admission (2.1 ± 1.8 vs. 5.7 ± 1.9, P < 0.001), 24 hours postoperatively (3.3 ± 1.0 vs. 5.4 ± 1.8, P < 0.001), and 48 hours postoperatively (3.2 ± 0.6 vs. 4.4 ± 1.4, P < 0.001). The proportion of patients requiring rescue analgesics in the recovery room was significantly lower in the epidural anesthesia group (1.9% vs. 20.5%, P = 0.027). The median 15-item Quality of Recovery score on postoperative day 1 was significantly higher in the epidural anesthesia group (118.0 [113.5-123.0] vs. 82.0 [73.5-111.5], P < 0.001). Occurrence of nausea, vomiting, and voiding difficulty up to 48 hours postoperatively did not differ between groups.

CONCLUSIONS

Compared with general anesthesia, epidural anesthesia provided better analgesia and recovery characteristics during the early postoperative period in endoscopic lumbar decompression surgery.

Effect Analysis of Epidural Anesthesia with 0.4% Ropivacaine in Transforaminal Endoscopic Surgery

Background

Epidural anesthesia used in percutaneous endoscopic lumber discectomy (PELD) has the risk of complete neurotactile block. Patients cannot timely respond to the operator when the nerve is touched by mistake, so the potential risk of nerve injury cannot be avoided. According to pharmacodynamics, with the decrease of local anesthetic concentration, the nerve tactile gradually recovered; however, the analgesic effect also gradually weakened. Therefore, it is necessary to explore an appropriate concentration of local anesthetics that can keep the patients' nerve touch without pain. By comparing the advantages and disadvantages of 0.4% ropivacaine epidural anesthesia, local anesthesia and intravenous anesthesia on intraoperative circulation fluctuation, the incidence of salvage analgesia and the incidence of nerve non-touch, the feasibility of using low concentration epidural anesthesia in PELD to obtain enough analgesia and avoid the risk of nerve injury was confirmed.

Methods

153 cases of intervertebral foramen surgery from October 2017 to January 2020 were selected and divided into local anesthesia group (LA group), 0.4% ropivacaine epidural anesthesia group (EA group), and intravenous anesthesia group (IVA group) according to different anesthesia methods. The changes of blood pressure and heart rate, the incidence of rescue analgesia and nerve root non-touch were compared among the three groups.

Results

The difference of map peak value among the three groups was statistically significant (P < 0.001); pairwise comparison showed that the map peak value of the LA group was higher than that of the EA group (P < 0.001) and IVA group (P < 0.001), but there was no statistical significance between the EA group and IVA group. The difference of HR peak value among the three groups was statistically significant; pairwise comparison showed that the HR peak value of the LA group was higher than that of the EA group (P < 0.001) and IVA group (P < 0.001), but there was no statistical significance between the EA group and IVA group. There was significant difference in the incidence of intraoperative hypertension among the three groups (P < 0.05); pairwise comparison showed that the incidence of intraoperative hypertension in the EA group was lower than that in the LA group (P < 0.05), while there was no significant difference between the IVA group, EA group, and LA group. There was significant difference in the incidence of rescue analgesia among the three groups (P < 0.01); pairwise comparison showed that the incidence of rescue analgesia in the EA group was lower than that in the LA group (P < 0.05) and IVA group (P < 0.05), but there was no significant difference between the LA group and IVA group. Due to the different analgesic mechanisms of the three anesthesia methods, local anesthesia and intravenous anesthesia do not cause the loss of nerve tactile, while the incidence of nerve tactile in 0.4% ropivacaine epidural anesthesia is only 2.4%, which is still satisfactory.

Conclusion

Epidural anesthesia with 0.4% ropivacaine is a better anesthesia method for PELD. It not only has a low incidence of non-tactile nerve, but also has perfect analgesia and more stable intraoperative circulation.

Percutaneous Endoscopic Interlaminar Discectomy with Modified Sensation-Motion Separation Anesthesia for Beginning Surgeons in the Treatment of L5-S1 Disc Herniation

Purpose

To compare the clinical effects of local anesthesia (LA), general anesthesia (GA) and modified sensation-motion separation anesthesia (MA) in percutaneous endoscopic interlaminar discectomy (PEID) in the treatment of L5/S1 lumbar disc herniation (LDH) for the purpose of guiding junior surgeons.

Methods

Eighty-four patients with L5/S1 LDH underwent PEID using three anesthesia methods. Patients in the LA (26), GA (29) and MA (29) groups received a follow-up examination retrospectively. The general parameters, preparation and anesthesia duration, operative duration, recovery time, incidence of complications, ambulation time, length of hospital stay, incidence of severe complications, and reoperation rate were compared, and clinical outcomes were analyzed using a visual analog scale (VAS), the Oswestry Disability Index (ODI), and the Short-Form Health Survey 36 (SF-36).

Results

MA demonstrated obvious advantages over the other two methods with respect to operative duration and resulted in a better intraoperative experience than LA. The patients in the MA group required less time in bed postoperatively and shorter hospital stays than those in the GA group. The mean postoperative VAS, ODI and SF-36 scores were significantly better than the preoperative scores in all groups (P<0.05), but no significant differences in these scores were found among the three groups (P>0.05). Three cases (3/29) of nervous disorder occurred in the GA group. Two patients (one in the GA group (1/29) and one in the LA (1/26) group) underwent revision surgery, with a total recurrence rate of 2.4% (2/84).

Conclusion

Due to its high safety and good tolerance by patients, MA is a suitable method for spinal surgeons who are inexperienced with PEID in the treatment of L5/S1 disc herniation.