Fragmentectomy versus Conventional Microdiscectomy in Single-Level Lumbar Disc Herniations : Comparison of Clinical Results and Recurrence Rates

Usefulness of Source Images of Magnetic Resonance Myelograms and Partial Laminectomy for Interlaminar Endoscopic Lumbar Discectomy at L5-S1: A Technical Note and Preliminary Clinical Results

ABSTRACT

The primary objective of this study was to assess the clinical and radiologic outcomes and introduce the technical notes from 10 patients who underwent interlaminar endoscopic lumbar discectomy (IELD) at L5-S1 using the source images of magnetic resonance (MR) myelograms and performing partial laminectomy. A biportal endoscopic system was used to perform partial laminectomy, followed by fragmentectomy and subtotal discectomy using a uniportal endoscopic system. The source images of MR myelograms were used to identify the anatomical relationship between the herniated disc material, L5 and S1 nerve roots, the thecal sac, and L5 lamina. Preoperative leg and back visual analog scale scores were greatly improved immediately and after 3 months and 6 months postoperatively. Fragmentectomy and subtotal discectomy became easier after performing a partial laminectomy in all IELD cases at L5-S1. The source images of MR myelograms and partial laminectomy is useful for IELD at L5-S1.

LEVEL OF EVIDENCE

Level IV.

Full endoscopic surgery for thoracic pathology: an assessment of supportive evidence

In the last five years, surgeons have applied endoscopic transforaminal surgical techniques mastered in the lumbar spine to the treatment of thoracic pathology.

The aim of this systematic review was to collate the available literature to determine the place and efficacy of full endoscopic approaches used in the treatment of thoracic disc prolapse and stenosis.

An electronic literature search of PubMed, Embase, the Cochrane database and Google Scholar was performed as suggested by the Preferred Reporting Items for Systematic Review and Meta-analysis statements. Included were any full-text articles referring to full endoscopic thoracic surgical procedures in any language.

We identified 17 patient series, one cohort study and 13 case reports with single or of up to three patients.

Although the majority included disc pathology, 11 papers related cord compression in a proportion of cases to ossification of the ligamentum flavum or posterior longitudinal ligament. Two studies described the treatment of discitis and one reported the use of endoscopy for tumour resection.

Where reported, excellent or good outcomes were achieved for full endoscopic procedures in a mean of 81% of patients (range 46–100%) with a complication rate of 8% (range 0–15%), comparing favourably with rates reported after open discectomy (anterior, posterolateral and thoracoscopic) or by endoscopic tubular assisted approaches. Twenty-one of the 31 author groups reported use of local anaesthesia plus sedation rather than general anaesthesia, providing ‘self-neuromonitoring’ by allowing patients to respond to cord and/or nerve stimuli.

Cite this article: EFORT Open Rev 2021;6:50-60. DOI: 10.1302/2058-5241.6.200080

A Pilot Study of Percutaneous Interlaminar Endoscopic Lumbar Sequestrectomy: A Modern Strategy to Tackle Medically-Refractory Radiculopathies and Restore Spinal Function

Objective

Angled scopes allow 360° visualization, which makes percutaneous endoscopic techniques (percutaneous endoscopic lumbar discectomy, PELD) particularly attractive for sequestrectomies, which entail the removal of extruded lumbar disc fragments that have migrated caudally or cranially between the ligaments, foramina, and neural structures, while preserving the disc. Although many different PELD techniques are currently available, not all of them are suitable for sequestrectomies; furthermore, long-term follow-up data are unfortunately lacking.

Methods

A pilot study was conducted on a cohort of 270 patients with lumbar radiculopathy undergoing minimally invasive spine surgery (PELD or microdiscectomy), of whom only 7 were eligible for endoscopic interlaminar sequestrectomy with disc preservation. The patients’ baseline conditions and clinical outcomes were measured with the Oswestry Disability Index and a visual analogue scale. Long-term follow-up was conducted using satisfaction questionnaires that were based on the MacNab criteria and administered by medical/nursing personnel not involved in their primary surgical management.

Results

EasyGo system was eventually used in 5 PELD cases. No dural tears, infections, or nerve root injuries were recorded in patients undergoing sequestrectomy. Surgical events, including blood loss and overall length of hospital stay, did not differ significantly among the 270 patients. In the group treated with endoscopic sequestrectomy, no recurrences or complications were noted during a follow-up of 3 years, and an excellent degree of satisfaction was reported.

Conclusion

We provide OCEBM (Oxford Centre for Evidence-Based Medicine) level 3 evidence that interlaminar endoscopic sequestrectomy is a tailored and well-tolerated surgical option; nonetheless, a cost-effectiveness analysis assessing the interval until return to working activities and long-term benefits is warranted.

[Rehabilitation of the patients presenting with the operated spine syndrome during the complicated postoperative period after discectomy]

This article presents an analytical review of the literature concerning the problem of rehabilitation of the patients following the surgical treatment of hernias of intervertebral disks. The relevance of this problem and the importance of the related research activities in the context of neurorehabilitation are beyond any doubt. Despite the obvious progress in the modernization of the methods and technologies for medical rehabilitation, the number of re-operations in connection with the recurrences of herniated discs remains too high and the overall success thus far achieved in this field falls short of expectations. The authors discuss in detail the need for and the contemporary approaches to the rehabilitative treatment of the patients undergoing vertebral microdiscectomy including medication therapy, physiotherapy an therapeutic physical exercises. The variants of the application of magnetic stimulation during the early period of the rehabilitative treatment of the patients following the minimally invasive interventions for discogenic radiculopathy are considered.

Primary Versus Revision Single-level Minimally Invasive Lumbar Discectomy: Analysis of Clinical Outcomes and Narcotic Utilization

STUDY DESIGN

Retrospective cohort analysis of a prospectively maintained registry.

OBJECTIVE

To compare the intraoperative variables, surgical outcomes, and narcotic utilization between primary and revision 1-level minimally invasive (MIS) lumbar discectomies.

SUMMARY OF BACKGROUND DATA

Revision spine surgery may be associated with longer procedural time and greater soft tissue disruption. Few studies have analyzed the surgical outcomes and narcotic utilization associated with MIS revision lumbar discectomies.

METHODS

A retrospective analysis of 227 consecutive cases of MIS 1-level lumbar discectomy for degenerative spinal pathology between 2009 and 2014 by a single surgeon was performed. Patients were stratified into primary and revision cohorts. Demographics, comorbidity, intraoperative parameters, peri- and postoperative outcomes, and reoperations were assessed. Postoperative narcotic utilization was compared between cohorts. Statistical analyses were performed using Student t-test and Pearson χ test. A P < 0.05 denoted statistical significance.

RESULTS

Of the 227 cases included, 186 patients (81.9%) and 41 patients (18.1%) were included in the primary and revision cohorts, respectively. Demographics, comorbidity, smoking status, preoperative visual analogue scale (VAS) scores, and estimated blood loss did not differ between cohorts. However, the revision cohort demonstrated a longer procedural time, increased length of hospitalization, and higher postoperative narcotic utilization. Although not statistically significant, revision patients trended toward higher 6-week postoperative VAS scores and reherniation rates. In addition, revision patients were more likely to undergo subsequent lumbar fusion than primary patients.

CONCLUSION

The findings suggest that revision MIS lumbar discectomy may be associated with increased procedural time, increased length of hospitalization, and increased postoperative narcotic utilization. Whereas revision patients trended toward higher postoperative VAS scores at 6 weeks, both cohorts demonstrated similar pain levels at final follow-up. Finally, revision patients may be at a greater risk of reherniation and subsequent reoperation. Further studies are warranted to characterize the independent risk factors for a revision lumbar discectomy.

LEVEL OF EVIDENCE

3.

Is sequestrectomy a viable alternative to microdiscectomy? A systematic review of the literature

BACKGROUND

Traditionally, lumbar discectomy involves removal of the free disc fragment followed by aggressive or conservative excision of the intervertebral disc. In selected patients, however, it is possible to remove only the free fragment or sequester without clearing the intervertebral disc space. However, there is some controversy about whether that approach is sufficient to prevent recurrent symptoms and to provide adequate pain relief.

QUESTIONS/PURPOSES

This systematic review was designed to pose two questions: (1) Does performing a sequestrectomy only without conventional microdiscectomy lead to an increased reherniation rate; and (2) is there a difference in the patient-reported levels of radicular pain?

METHODS

Systematic MEDLINE and EMBASE searches were carried out to identify all articles published in peer-reviewed journals reporting the outcomes of interest for conventional microdiscectomy versus sequestrectomy for lumbar disc herniation from L2 to the sacrum (Level III evidence and above); hand-searching of bibliographies was also performed. A minimum of Level II evidence was required with a followup rate of greater than 75%. Followup in all studies was from 18 to 86 months. Seven studies met the inclusion criteria for this review. The studies were analyzed for operating time, hospital stay, pre- and postoperative visual analog scale, and reherniation rate.

RESULTS

Patients in both the microdiscectomy and sequestrectomy groups showed comparable improvement of visual analog scale (VAS) score for leg pain. VAS score improvement ranged from 5.6 to 6.5 points in the microdiscectomy groups and 5.5 to 6.6 in the sequestrectomy group. The reherniation rate in the microdiscectomy group ranged from 2.3% to 11.8% and in the sequestrectomy groups from 2% to 12.5%.

CONCLUSIONS

This review of the available literature suggests that, compared with conventional microdiscectomy, microsurgical lumbar sequestrectomy can achieve comparable reherniation rates and reduction in radicular pain when a small breach in the posterior fibrous ring is found intraoperatively.

Comparison of discectomy versus sequestrectomy in lumbar disc herniation: a meta-analysis of comparative studies

Background

Lumbar disc removal is currently the standard treatment for lumbar disc herniation. No consensus has been achieved whether aggressive disc resection with curettage (discectomy) versus conservative removal of the offending disc fragment alone (sequestrectomy) provides better outcomes. This study aims to compare the reherniation rate and clinical outcomes between discectomy and sequestrectomy by literature review and a meta-analysis.

Methods

A systematic search of PubMed, Medline, Embase and the Cochrane Library was performed up to June 1, 2014. Outcomes of interest assessing the two techniques included demographic and clinical baseline characteristics, perioperative variables, complications, recurrent herniation rate and post-operative functional outcomes.

Results

Twelve eligible trials evaluating discectomy vs sequestrectomy were identified including one randomized controlled study, five prospective and six retrospective comparative studies. By contrast to discectomy, sequestrectomy was associated with significantly less operative time (p<0.001), lower visual analogue scale (VAS) for low back pain (p<0.05), less post-operative analgesic usage (p<0.05) and better patients’ satisfaction (p<0.05). Recurrent herniation rate, reoperation rate, intraoperative blood loss, hospitalization duration and VAS for sciatica were without significant difference.

Conclusions

According to our pooled data, sequestrectomy entails equivalent reherniation rate and complications compared with discectomy but maintains a lower incidence of recurrent low back pain and higher satisfactory rate. High-quality prospective randomized controlled trials are needed to firmly assess these two procedures.