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

Comparison of Full Endoscopic Lumbar Diskectomy Using the Transforaminal Approach versus Interlaminar Approach for L5-S1 Lumbar Disk Herniation Treatment: A Meta-Analysis

BACKGROUND

 Numerous studies have examined the clinical effectiveness of transforaminal full endoscopic lumbar diskectomy (T-FELD) and interlaminar full endoscopic lumbar diskectomy (I-FELD) for L5-S1 lumbar disk herniation (LDH), with mixed findings. The goal of this systematic review and meta-analysis was to evaluate the perioperative outcomes, clinical results, and complications of T-FELD and I-FELD to determine their efficacy and safety for treating L5-S1 LDH and to examine the features of complications in depth.

METHODS

 Several databases were searched for articles that matched all of the inclusion criteria. The visual analog scale (VAS) and Oswestry Disability Index (ODI) were used to assess the clinical results. Information on perioperative outcomes and complications was gathered and analyzed.

RESULTS

 Eight studies with 756 participants were included. There were no significant differences in postoperative bed time (p = 0.44) and hospitalization time (p = 0.49) between T-FELD and I-FELD. When compared with I-FELD, T-FELD was associated with substantially longer fluoroscopy time (p < 0.0001) and operating time (p < 0.0001). There were no significant differences in the preoperative and postoperative VAS and ODI scores between T-FELD and I-FELD. The rates for overall complications, postoperative dysesthesia, postoperative lower extremity pain, incomplete decompression, recurrence, and conversion to open surgery were comparable for T-FLED and I-FELD.

CONCLUSION

 T-FELD and I-FELD had equal clinical results and safety for treatment of L5-S1 LDH. Fluoroscopy and operative times were shorter for I-FELD than for T-FELD.

Role of surgery in primary lumbar disk herniation: WFNS spine committee recommendations

Objective

To provide the most up-to-date recommendations on the role of surgery in first-time lumbar disk herniations (LDH) in order to standardize surgical management.

Methods

We performed a literature search in PubMed, Scopus, and Embase from 2012 to 2022 using the following keywords: "lumbar disk herniation AND surgery". Our initial search yielded 2610 results, which were narrowed down to 283 papers after standardized screening critera were applied. The data from these 283 papers were presented and discussed at two international meetings of the World Federation of Neurosurgical Societies (WFNS) Spine Committee, where the Delphi method was employed and ten spine experts voted on five final consensus statements.

Results

and Conclusions: The WFNS Spine Committee's guidelines cover four main topics: (1) role and timing of surgery in first-time LDH; (2) role of minimally invasive techniques in LDH; (3) extent of disk resection in LDH surgery; (4) role of lumbar fusion in the context of LDH. Surgery for LDH is recommended for failure of conservative treatment, cauda equina syndrome, and progressive neurological impairment, including severe motor deficits. In the latter cases, early surgery is associated with faster recovery and may improve patient outcomes. Minimally invasive techniques have short-term advantages over open procedures, but there is insufficient evidence to make a recommendation for or against the choice of a specific surgical procedure. Sequestrectomy and standard microdiscectomy demonstrated similar clinical results in terms of pain control, recurrence rate, functional outcome, and complications at short and medium-term follow-up. Lumbar fusion is not recommended as a routine treatment for first-time LDH, although it may be considered in specific patients affected by chronic axial pain or instability.

An Effectiveness Evaluation of Nucleo-Annuloplasty for Lumbar Discogenic Lesions Using Disc-FX: A Scoping Review

Background and Objectives: Degenerative disk disease is a widespread chronic condition that causes diskogenic pain. Diskogenic pain can be treated with various therapy methods. Disc-FX is a revolutionary, minimally invasive, percutaneous nucleo-annuloplasty method that combines manual diskectomy with nuclear and annular remodeling using radiofrequency ablation to relieve diskogenic pain. In this study, the technical features, clinical outcomes, and complications of Disc-FX are summarized. Materials and Methods: A comprehensive literature review was performed. By exploring several databases, we collected studies on Disc-FX for treating diskogenic pain. The outcomes included perioperative data, clinical results, and complications. Results: In the 15 studies included, data from 570 patients were collected. L4-L5 was the most frequently operated level, and most cases underwent single-level procedures. The follow-up period for these patients ranged from 2 months to 24 months. One study reported a procedure time between 35 and 60 min, whereas the remaining studies reported a procedure time of less than 30 min. The mean visual analog scale score decreased from 7.22 preoperatively to 1.81 at the final follow-up. The mean numerical rating scale score decreased from 6.98 preoperatively to 3.9 at the final follow-up. The mean Japanese Orthopaedic Association score improved from 16.26 preoperatively to 25.88 in the final follow-up. The mean Oswestry Disability Index score decreased from 35.37 preoperatively to 14.66 at the final follow-up. The mean satisfaction rate (based on the Macnab criteria) was 87.6% (range, 78.4-95.2%). The total incidence of postoperative transient pain was 8.77% (50/570) after nucleo-annuloplasty using Disc-FX, and recurrence was 1.58% (9/570). Conclusions: According to our comprehensive evaluation, using percutaneous nucleo-annuloplasty for treating lumbar diskogenic diseases provided considerable pain alleviation and improved functional outcomes with fewer complications. Disc-FX is a safe and effective procedure that is a good treatment option for patients with diskogenic pain.

Evaluation of Endoscopic Versus Open Lumbar Discectomy: A Multi-Center Retrospective Review Utilizing the American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP) Database

Introduction: Endoscopic techniques in spine surgery continue to gain popularity due to their potential for decreased blood loss and post-operative pain. However, limited studies have evaluated these techniques within the United States. Additionally, given the limited number of practitioners with experience in endoscopy, most current studies are limited by a lack of heterogeneity.

Methods: The American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to evaluate the effect of endoscopic surgery on adverse events. Current Procedural Terminology (CPT) codes for open discectomy were compared with the relevant CPT codes for endoscopic lumbar discectomy. Baseline patient characteristics and adverse outcomes were then compared. 

Results: A total of 38,497 single-level lumbar discectomies were identified and included. Of these, 175 patients undergoing endoscopic discectomy were compared with 38,322 patients undergoing open discectomy. Endoscopic discectomy demonstrated a shorter operative time of 88.6 minutes than 92.1 minutes in the open group. However, this was not significant (p=0.08). Patients in the endoscopic group demonstrated a shorter total length of stay of 0.81 days vs 1.15 days (p=0.014). Total adverse events were lower in the endoscopic group at 0.6% vs 3.4% in the open group (p=0.03).

Conclusion: Endoscopic discectomy demonstrated a significantly lower rate of adverse events and shorter total length of stay than open discectomy. Further research is necessary over time to evaluate larger patient populations as this technology is more rapidly incorporated.