Percutaneous endoscopic lumbar discectomy: Results of first 100 cases

The Current Status of Awake Endoscopic Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

To examine the use of local anesthesia and/or conscious sedation in endoscopic spine procedures within the past decade.

METHODS

This systematic review abided by PRISMA guidelines. Embase, PubMed, Google Scholar, and Cochrane databases were searched for post-2011 articles with patients >18 years old, lumbar/cervical percutaneous endoscopic spine procedures using local/awake anesthesia, and patient/surgical outcomes. Reviews, book chapters, single case reports, or small case series (n ≤15 patients) were excluded. Scoring systems of the National Institutes of Health quality assessment tool, Newcastle-Ottawa Scale, and Cochrane Risk of Bias evaluated interventional case series, comparative studies, and randomized control trials, respectively.

RESULTS

Twenty-six articles were included, with 4 studies comparing general and local anesthesia. Of 2113 total patients, 1873 patients received local anesthesia. Significant improvements were seen in pain and disability scores. Studies that included MacNab scores showed that 96% of patients rated their postoperative satisfaction as excellent to good. Subanalysis of comparative studies showed a reduced risk of surgical/major medical complications and a slight increased risk for minor medical complications among awake spine patients. Length of stay was shorter for patients receiving local anesthesia.

CONCLUSIONS

The current systematic review and meta-analysis shows that use of local anesthesia is a safe and effective alternative to general anesthesia among different endoscopic spinal procedures. Although awake spine surgery is associated with a decreased risk of severe complications, lower revision rates, and higher postoperative satisfaction, more robust studies involving larger cohorts of patients are needed to evaluate the true impact of awake spine surgery on outcomes.

Reducing the learning curve of interlaminar full-endoscopic discectomy: mushroom model-simulation training

PURPOSE

To describe a cheap simulation model used to reduce the learning curve of the interlaminar full-endoscopic discectomy in a pilot study.

INTRODUCTION

The steep and difficult learning curve remain one of the main obstacles against the widespread diffusion of interlaminar full endoscopic lumbar discectomy (ILFED). One solution to overcome this learning curve is training with deliberate practice. As realistic models are relatively expensive and cadaver workshops not readily available, we developed a simple and cheap model to train the key steps of the procedure.

METHODS

A simple and cheap model were designed. It consists of a king oyster mushroom stalk, a glove finger, a sponge and cotton wool. In order to fix the model to the table and to simulate the level of the patient's skin whereupon the hand of the surgeon relies, a wooden holding device was also used. As the purpose of this pilot study was to evaluate the model as a stimulator, it was tested during an advanced endoscopic training course.

RESULTS

A step-by-step learning method with key steps was used by participants attending an advanced ILFED training on expensive realistic models. The model was considered as comparable and enough realistic to train key steps in order to reduce the learning curve and training costs.

CONCLUSION

We present an affordable, simple and reproducible training model, which allows for deliberate practice of the key steps of the ILFED procedure. The model may be used by surgeons starting with spinal endoscopy.

Return-to-Play Outcomes of Athletes After Operative and Nonoperative Treatment of Lumbar Disc Herniation

PURPOSE OF REVIEW

Lumbar disc herniation (LDH) is a common injury experienced by athletes and has important clinical considerations for athletes including the timing of return to sport. Lumbar disc herniation may result in loss of individual training and playing time for athletes. Current literature is inconclusive on whether surgical or conservative treatment of LDH is superior in athletes. Our aim was to review the literature to identify return-to-play (RTP) rates and performance outcomes following operative and nonoperative treatment of LDH in the athletic population.

RECENT FINDINGS

Athletes have unique measurements of successful treatment for LDH such as time to return to their sport and performance outcomes that are not as applicable as traditional metrics. It is suggested that surgical treatment may provide a quicker return to sport than nonoperative care in athletes. Additionally, conflicting findings have been seen in career length and performance status based on sport, often due to short and tumultuous career patterns. These differences may be seen based on the unique physical demands of each sport, different motivations to prolong sport, or other confounding factors that could not be controlled for or unrelated to LDH. Recent literature on RTP outcomes in athletes treated for LDH show variable results based on sport. Further research is needed to assist physicians and athletes in making the decision to undergo conservative or surgical treatment of LDH in the athletic population.

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

Aim: Endoscopic discectomies provide several advantages over other techniques such as traditional open lumbar discectomy (OLD) including possibly decreased complications, shorter hospital stay and an earlier return to work. Methods: An electronic database search including MEDLINE/PubMed, EMBASE, Scopus, Cochrane Database of Systematic Reviews and Cochrane Controlled trials (CENTRAL) were reviewed for randomized controlled trials (RCTs) only. Results: A total of nine RCTs met inclusion criteria. Three showed benefit of endoscopic discectomy over the comparator with regards to pain relief, with the remaining six studies showing no difference in pain relief or function. Conclusion: Based on review of the nine included studies, we can conclude that endoscopic discectomy is as effective as other surgical techniques, and has additional benefits of lower complication rate and superior perioperative parameters.

Surgical Outcomes for Upper Lumbar Disc Herniations: A Systematic Review and Meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To conduct a literature review on outcomes of discectomy for upper lumbar disc herniations (ULDH), estimate pooled rates of satisfactory outcomes, compare open laminectomy/microdiscectomy (OLM) versus minimally invasive surgical (MIS) techniques, and compare results of disc herniations at L1-3 versus L3-4.

METHODS

A systematic review of articles reporting outcomes of nonfusion surgical treatment of L1-2, L2-3, and/or L3-4 disc herniations was performed. The inclusion and exclusion of studies was performed according to the latest version of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

RESULTS

A total of 20 articles were included in the quantitative meta-analysis. Pooled proportion of satisfactory outcome (95% CI) was 0.77 (0.70, 0.83) for MIS and 0.82 (0.78, 0.84) for OLM. There was no significant improvement with MIS techniques compared with standard OLM, odds ratio (OR) = 0.86, 95% CI (0.42, 1.74), P = .66. Separating results by levels revealed a trend of higher satisfaction with L3-4 versus L1-3 with OLM surgery, OR = 0.46, 95% CI (0.19, 1.12), P = .08.

CONCLUSION

Our analysis reveals that discectomy for ULDH has an overall success rate of approximately 80% and has not improved with MIS. Discectomy for herniations at L3-4 trends toward better outcomes compared with L1-2 and L2-3, but was not significant.

Percutaneous Endoscopic Lumbar Discectomy for Lumbar Disc Herniation Using an Endoscopic Staining: A Technical Note

Symptomatic lumbar disc herniation (LDH) is widely treated using percutaneous endoscopic lumbar discectomy (PELD). In the present PELD surgery, performing decompression under endoscope still takes a long time to explore the rupture site of annulus fibrosus, resulting in prolonged operation time and over-invasion of the undegenerated annulus fibrosus. A wide range of intraoperative exploration also induces an iatrogenic injury of the normal annulus fibrosus, even aggravating intervertebral disc degeneration, which may lead to early postoperative recurrence in severe case. Hence, it is important to seek a precise decompression in PELD surgery. Under this kind of realization, more spinal surgeons possibly choose a disc staining before performing decompression. However, the classical disc staining technique still has its shortcomings. First of all, an appropriate dose of staining cannot be accurately mastered, even induces unqualified staining effect. Second, the duration of surgery and the times of fluoroscopy will be increased. Finally, what surgeons see under the endoscope is the staining result but not the staining process. Hence, this is accomplished more effectively by designing procedures that perform fully visible disc staining under spinal endoscope. There is no specific research to discuss the technique note of endoscopic staining in PELD surgery. We have come up with a new original technology of endoscopic staining with methylene blue injection in PELD for treatment of LDH.

Return to the Original Work Activity Following the Full-endoscopic Lumbar Surgery under the Local Anesthesia

Transforaminal full-endoscopic spine (TF-FES) surgery is minimally invasive and can be performed under local anesthesia. Thus, it is expected that the patient can return to work (RTW) quickly. However, information in the literature regarding this is sparse. The purpose of this study is to review the timing of RTW after TF-FES surgery. This study involved 50 patients (14 women, 36 men; mean age 44.5 years, age range: 20-65 years) who underwent TF-FES surgery between January 2016 and April 2018. All the patients were active workers. Occupations varied widely (e.g., physician, nurse, helper, clerk, construction worker, chef, and schoolteacher). There were no surgery-related complications. Median time to RTW was 21 days. More than half of the patients could RTW within 21 days. In all, 12 cases (24%) could have RTW within 7 days. Occupations of 12 patients who achieved RTW within 7 days included physician, company owner, and restaurant owner, with 11 in the Light work, 1 was in the Medium work, and none in the Heavy work. All 12 had a quick RTW because their work was Light and they could not take prolonged sick leave. Prompt RTW is possible with TF-FES surgery. The biggest merit of TF-FES surgery is minimal invasiveness to the muscles of the back. Also, it can be performed under local anesthesia. Our findings reveal quicker RTW after surgery, depending on occupational type.

Return to Play After Symptomatic Lumbar Disc Herniation in Elite Athletes: A Systematic Review and Meta-analysis of Operative Versus Nonoperative Treatment

Context:

The prevalence of symptomatic lumbar disc herniation (LDH) in athletes can be as high as 75%. For elite athletes diagnosed with LDH, return to play (RTP) is a major concern, and thus comparing surgical with nonoperative care is essential to guide practitioners and athletes, not just in terms of recovery rates but also speed of recovery.

Objective:

The purpose of this systematic review is to provide an update on RTP outcomes for elite athletes after lumbar discectomy versus nonoperative treatment of LDHs.

Data Sources:

A search of the literature was conducted using 3 online databases (MEDLINE, EMBASE, and PubMed) to identify pertinent studies.

Study Selection:

Yielded studies were screened according to the inclusion criteria.

Study Design:

Systematic review with meta-analysis.

Level of Evidence:

Level 4.

Data Extraction:

Relevant data were extracted. A meta-analysis was performed comparing RTP rate for all comparative studies.

Results:

Twenty studies met the inclusion criteria and were included in this review. Overall, 663 out of 799 patients (83.0%) returned to play in the surgical group and 251 out of 308 patients (81.5%) returned to play in the nonoperative group. No statistically significant difference for RTP rate was found (odds ratio, 1.39; 95% CI, 0.58-3.34; P = 0.46; I2, 71%). The mean time to RTP for patients undergoing lumbar discectomy was 5.19 months (range 1.00-8.70 months), and 4.11 months (range 3.60-5.70 months) for those treated conservatively.

Conclusion:

There was no significant difference in RTP rate between athletes treated with operative or nonoperative management of LDHs, nor did operative management have a faster time to RTP. Athletes should consider the lack of difference in RTP rate in addition to the potential risks associated with spinal surgery when choosing a treatment option. Future randomized controlled trials are needed on this topic to allow for high-powered conclusions.

Comparison of Interlaminar and Transforaminal Approaches for Treatment of L5 /S1 Disc Herniation by Percutaneous Endoscopic Discectomy

Objective

The aim of this study was to compare the clinical efficacy of percutaneous endoscopic interlaminar discectomy (PEID) and percutaneous endoscopic transforaminal discectomy (PETD) in treating L₅/S₁ disc herniation.

Methods

A retrospective analysis of 76 patients with L₅/S₁ intervertebral disc herniation was performed. There were two surgical treatment groups: one with patients receiving PEID and the other with patients receiving PETD. The two groups were compared by length of surgery, times of intraoperative X‐ray exposure, postoperative time in bed, length of hospital stay, operative complications, patient's assessment of pain using a visual analogue scale (VAS), and disability using the Oswestry disability index (ODI) before and after surgery.

Results

Subjects in the PEID group were in surgery for 60.90 ± 13.11 min and needed intraoperative X‐ray exposure 4.10 ± 1.09 times. Patients in this group were ambulatory by 7.52 ± 1.08 h after surgery and were hospitalized for 5.05 ± 0.92 days. In contrast, patients in the PETD group were in surgery for 84.06 ± 15.58 min and needed intraoperative X ray exposure 12.81 ± 8.46 times. These patients were ambulatory by 7.06 ± 0.91 h after surgery and remained in the hospital for 4.94 ± 0.80 days. Based on these data, operation time and fluoroscopy time were significantly less (P < 0.002 and P < 0.001, respectively) for subjects in the PEID group. However, ambulatory time and hospitalization were similar for both in terms of pain relief and decreased disability, and subjects in both groups responded well to the surgery and showed a significant decrease in both VAS and ODI scores at their 1‐year follow‐up (P < 0.01). Furthermore, there were no statistically significant differences between the two surgeries in terms of pain relief and decrease in disability.

Conclusion

For L₅/S₁ disc herniation, PEID and PETD provide similar results for patients. However, PEID has the advantage over PETD in that it is a shorter procedure and exposes the patient to less radiation.

Keywords

Comparison of microendoscopic discectomy and open discectomy for single-segment lumbar disc herniation

BACKGROUND

Lumbar disc herniation is a common disease. Endoscopic treatment may have more advantages than traditional surgery.

AIM

To compare the clinical efficacy and safety of microendoscopic discectomy (MED) and open discectomy with lamina nucleus enucleation in the treatment of single-segment lumbar intervertebral disc herniation.

METHODS

Ninety-six patients who were operated at our hospital were selected for this study. Patients with single-segment lumbar disc herniation were admitted to the hospital from March 2018 to March 2019 and were randomly divided into the observation group and the control group with 48 cases in each group. The former group underwent lumbar discectomy and the latter underwent laparotomy and nucleus pulpectomy. Surgical effects were compared between the two groups.

RESULTS

In terms of surgical indicators, the observation group had a longer operation time, shorter postoperative bedtime and hospital stay, less intraoperative blood loss, and smaller incision length than the control group (P < 0.05). The excellent recovery rate did not differ significantly between the observation group (93.75%) and the control group (91.67%). Visual analogue scale pain scores were significantly lower in the observation group than in the control group at 1 d, 3 d, 1 mo, and 6 mo after surgery (P < 0.05). The incidence of complications was significantly lower in the observation group than in the control group (6.25% vs 22.92%, P < 0.05).

CONCLUSION

Both MED and open discectomy can effectively improve single-segment lumbar disc herniation, but MED is associated with less trauma, less bleeding, and a lower incidence of complications.

Cauda Equina Syndrome: A Review of 15 Patients Who Underwent Percutaneous Transforaminal Endoscopic Lumbar Discectomy (PTELD) Under Local Anaesthesia

INTRODUCTION

To analyse the results of Cauda Equina Syndrome (CES) operated by Percutaneous Transforaminal Endoscopic Lumbar Discectomy (PTELD).

MATERIAL AND METHODS

The study is a retrospective series of 15 patients operated by PTELD. Bladder dysfunction was classified as incomplete CES (CESI) and complete CES retention (CESR). Bladder / motor recovery rate and its timing, Oswestry Disability Index (ODI), Visual Analogue Score (VAS), patient satisfaction index, and sexual dysfunction were used to measure the outcome objectively. Additionally, in CESR patients, post-void residual (PVR) urine was measured by sonography. Complications and technical problems were noted.

RESULTS

There were ten patients of CESI and five patients of CESR. The average follow-up was 20.33(12.05) months. Bladder symptoms recovery was 100%, and motor recovery was 80%. VAS for back pain recovered to 0.53(0.52) from 8(2.39). VAS for leg pain recovered to 0.13(0.35) from 9.20(1.32). ODI improved to 6.07(2.85) from 77.52(13.20). The time to the recovery of bladder function was 1.47(1.55) days. All CESR patient's abnormal PVR urine was normalised at five weeks post-operative. No complications were reported. However, five technical executional problems occurred.

CONCLUSION

PTELD can be considered for CES treatment due to its substantial and quick recovery advantages. However, more evidence support is needed to make it a practice recommendation.

Successful full-endoscopic decompression surgery under local anesthesia for L5 radiculopathy caused by L5-Sforaminal stenosis and L4-5 lateral recess stenosis : A case report

In this report, we presented a 65 year-old male case having right leg pain due to L5 radiculopathy. Based on the radiological examination including CT, MRI and radiculography, double crash impingement of L5 nerve root due to L4-5 lateral recess and L5-S foraminal stenosis was diagnosed. Because of the strong pain, he could not work anymore. His job was a general manager of big hospital, he needed to return to job as soon as possible. We decided to conduct the full-endoscopic decompression surgery of ventral facetectomy (FEVF) for L4-5 lateral recess stenosis and foraminoplasty (FELF) for L5-S foraminal stenosis. The technique can be done under the local anesthesia with only 8 mm skin incision; thus, it must be the least invasive spine surgery. Soon after the surgery, he could return to the original job as a general manager. In conclusion, the full-endoscopic decompression surgery for the spinal canal stenosis such as FELF and FEVF would be minimally invasive procedure and it enable patients the quick return to the original activity. J. Med. Invest. 67 : 192-196, February, 2020.

Early return to activity after minimally invasive full endoscopic decompression surgery in medical doctors

Full endoscopic surgery including discectomy (FED) and ventral facetectomy (FEVF) is a minimally invasive lumbar decompression surgery that only requires an 8 mm skin incision and can be done under the local anesthesia and sedation. Six male medical doctors underwent the endoscopic decompression (FED/FEVF) for common degenerative lumbar spine problems. Their age ranged from 27 to 63 years of age with a mean of 40 years. Five doctors underwent FED surgery for herniated nucleus pulposus (HNP), and the remaining one physician had FEVF for lumbar lateral recess stenosis. There were no surgery related complications. Postoperatively, 5 out of the 6 physician patients returned the original job within a week because they had clinical duties. The shortest duration to return to work was reported by a 63-year-old orthopedic surgeon resumed working in his clinic 2 days after the FEVF surgery. The longest duration to return to work occurred in general medicine resident who took almost 2 weeks for the sick leave because he did not have clinical duties. The mean duration for the returning to work was 5.8 days after the surgery. At final follow-up ranging from 6 to 30 months, all physician patients were working without any residual pain. In the hands of the authors, the full endoscopic transforaminal decompression surgery is the preferred surgical option and allowed early return to work-an observation that is not the norm in Japan.

Return to play in professional baseball players following transforaminal endoscopic decompressive spine surgery under local anesthesia

Transforaminal endoscopic discectomy has been established as the least minimally invasive spine surgical procedure because it avoids the surgical morbidity from surgical dissection and denervation of normal anatomy responsible for the functional stability of the spine. There have been few reports on endoscopic spine surgery for professional athletes who are dependent on the preservation of vital anatomy to maintain the highest level of function. This report is on five Japanese professional baseball players who underwent transforaminal endoscopic foraminoplasty-discectomy with pulsed radiofrequency thermal annuloplasty under the local anesthesia. There were no adverse surgical events nor complications. Three athletes suffered from discogenic back pain, one from symptomatic herniated nucleus pulposus (HNP), and another player from sciatica due to foraminal stenosis. Three players decided to undergo surgery at the beginning of the off-season. Therefore, they returned to professional play at the beginning of the following season. The remaining two players underwent surgery just before the beginning of the next season. They all returned to play sooner than with traditional open decompression. Two players returned to play about one month after the start of the season. All five players quickly returned to their sport within three months despite the rigors required of their sport to maintain high proficiency and were able to complete the season.

Feasibility of Virtual Reality Combined with Isocentric Navigation in Transforaminal Percutaneous Endoscopic Discectomy: A Cadaver Study

Objectives

Transforaminal percutaneous endoscopic discectomy (TPED) is one of the most commonly used minimally invasive spine surgeries around the world. However, conventional surgical planning and intraoperative procedures for TPED have relied on surgeons’ experience, which limits its standardization and popularization. Virtual reality (VR) is a novel technology for pre‐surgical planning in various fields of medicine, while isocentric navigation can guide intraoperative procedures for TPED. The present study aimed to explore the feasibility of applying VR combined with isocentric navigation in TPED on cadavers.

Methods

The surgical levels were L₃/L₄ and L₄/L₅ as well as L₅/S₁ of both sides of each cadaver specimen. First, the surgeon manually conducted the above procedures on the left side of every specimen without preoperative simulation and isocentric navigation (Group A). Then the same surgeon conducted the VR simulation for surgical planning of the right side (Group B). After VR simulation, the same surgeon made the percutaneous punctures and placed the working channel on the right side of the specimen at all levels.

Results

At the L₃/L₄ level, the puncture‐channel time was 11.36 ± 2.13 min in Group A and 11.29 ± 2.23 min in Group B (t = 0.097, P = 0.938). The exposure time was 17.21 ± 2.91 s in Group A and 14.64 ± 1.60 s in Group B (t = 2.534, P = 0.025). At the L₄/L₅ level, the puncture‐channel time was 13.86 ± 3.90 min in Group A and 11.93 ± 2.95 min in Group B (t = 2.291, P = 0.039). Exposure time was 20.64 ± 3.84 s in Group A and 16.43 ± 2.47 s in Group B (t = 6.118, P < 0.01). There were 7 patients undergoing foraminotomy in Group A and 3 patients undergoing foraminotomy in Group B (t = 2.280, P = 0.236). At the L₅/S₁ level, the puncture‐channel time was 18.21 ± 1.85 min in Group A and 15.71 ± 3.20 min in Group B (t = 2.476, P = 0.028). Exposure time was 26.07 ± 3.17 s in Group A and 22.50 ± 2.68 s in Group B (t = 2.980, P = 0.011). There were 14 patients receiving foraminotomy in Group A and 13 patients receiving foraminotomy in Group B (t = 1.000, P = 1.000).

Conclusions

Virtual reality combined with isocentric navigation is feasible in TPED. It enables precise surgical planning and improves intraoperative procedures, and has the potential for application in clinical practice.

Mixed Reality-Based Preoperative Planning for Training of Percutaneous Transforaminal Endoscopic Discectomy: A Feasibility Study

OBJECTIVE

To explore the effect of preoperative planning using mixed reality (MR) on training of percutaneous transforaminal endoscopic discectomy (PTED).

METHODS

Before the training, we invited an experienced chief physician to plan the puncture path of PTED on the X-ray films of the lumbar spine model and the 3D Slicer platform, respectively, and used this as the standard to guide trainees. In the aggregate, 60 young residents were randomly divided into Group A (N = 30) and Group B (N = 30). Group A learned the 2-dimensional standard planning route, whereas Group B learned the standard route planning based on MR through the 3D Slicer platform. Then, trainees were asked to conduct PTED puncture on a lumbar spine model. Questionnaires were distributed to trainees before and after the training. During the training, puncture times, operating time (minutes), and fluoroscopy times were recorded.

RESULTS

After the training, it was obvious that more trainees showed their recognition of MR, believing that MR could help preoperative planning and training of PTED. Their high satisfaction with the training indicated the success of our training. Moreover, puncture times, operating time (minutes), and fluoroscopy times of Group B were significantly lower than those of Group A.

CONCLUSIONS

MR technology contributes to preoperative planning of PTED and is beneficial in the training of PTED. It significantly reduces puncture times and fluoroscopy times, providing a standardized method for the training of PTED.

Full Endoscopic Discectomy Using Transforaminal Endoscopic Spine System Technique: A Mini Review of Complications

Background:

Full Endoscopic Discectomy (FED) is a minimally invasive technique for the treatment of Lumbar Disk Herniation (LDH) with increasing popularity among surgeons in the recent years. This alternative to conventional procedures surgical approach is generally a safe and efficient technique possessing many advantages such as less soft tissue trauma, preservation of dorsal musculature, and reduced perioperative morbidity and rapid recovery. However, FED is associated with a number of complications such as postoperative dysesthesia, nerve root injury, and dural tears.

Methods:

Α search of PubMed, Google Scholar and Scopus electronic databases was used to revised the literature on complications of full endoscopic discectomy using transforaminal endoscopic spine system technique

Conclusion:

In this review complications associated with FED are analyzed, emphasizing on the potential beneficial role of Transforaminal Endoscopic Spine System (TESSYS) technique in reducing their frequency.

A comparative study on short-term therapeutic effects of percutaneous transforaminal endoscopic discectomy and microendoscopic discectomy on lumbar disc herniation

Objective:

To find out the short-term effects of percutaneous transforaminal endoscopic discectomy (PTED) and microendoscopic discectomy (MED) on lumbar disc herniation (LDH).

Methods:

Ninety LDH patients treated in PLA Army General Hospital from July 2015 to July 2016 were selected and randomly divided into an MED group and a PTED group. Length of incision, amount of intraoperative bleeding, surgical time, number of times using intraoperative fluoroscopy, postoperative bedridden time, hospital stay, together with visual analogue scale (VAS) and Oswestry disability index (ODI) scores before surgery, three days, three months and six months after surgery were analyzed.

Results:

As regards the length of surgical incision, amount of bleeding, postoperative bedridden time and hospital stay, the PTED group was significantly superior to the MED group ((P=0.000, 0.000, 0.000, 0.001, respectively)). Compared with the PTED group, the MED group used less fluoroscopy and had shorter surgical time (P=0.001, 0.000, respectively). The postoperative VAS and ODI scores of both groups were significantly improved compared with those before surgery (P<0.000, 0.000, respectively). The short-term postoperative low back pain (LBP) VAS score of PTED group was lower than that of MED group (P=0.001). The two groups had similar leg pain (LP) VAS score three and six months after surgery, postoperative and follow-up LP VAS and ODI scores, and surgical improvement rate (P=0.093, 0.097, respectively).

Conclusion:

LDH was effectively treated by both PTED and MED. Compared with MED, PTED had less trauma, less blood loss, and faster recovery after surgery.

Isocentric Navigation for the Training of Percutaneous Endoscopic Transforaminal Discectomy: A Feasibility Study

Background

Percutaneous endoscopic transforaminal discectomy (PETD) is usually chosen for lumbar disc herniation due to its obvious advantages such as small incision and absence of nerve or muscular traction. However, learning PETD is a great challenge for inexperienced surgeons.

Objective

The study aimed to investigate whether isocentric navigation would be beneficial in PETD training.

Methods

A total of 117 inexperienced surgeons were trained with PETD at L2/3, L3/4, L4/5, and L5/S1 on the cadavers without (Group A n=58) or with (Group B n=59) isocentric navigation. Puncture times, fluoroscopy times, exposure time, and radiation dose were recorded and analyzed. Questionnaires were conducted before and after the training program.

Result

Isocentric navigation could improve young surgeons' satisfaction with the training program and decrease the puncture times, fluoroscopy times, exposure time, and radiation dose significantly (P<0.001).

Conclusion

Isocentric navigation contributes to the training of PETD and may improve its standardization, homogenization, and generalization.

[Effect and effectiveness analysis of different approaches of transforaminal endoscope on extirpation amount of nuclues pulposus]

Objective

To investigate the effect and effectiveness analysis of different approaches of transforaminal endoscope on extirpation amount of nuclues pulposus.

Methods

Between August 2011 and December 2014, a total of 165 patients with lumbar disc herniation were retrospectively enrolled and were treated with nucleus pulposus discectomy through transforaminal endoscope. The patients were randomly divided into 4 groups according to different approach of transforaminal endoscope. The posterolateral approach (Yeung's technology) was used in group A (42 cases), transforaminal endoscopic spine system (TESSYS) technology was used in group B (40 cases), improved transforaminal endoscopic access (ITEA) technology was used in group C (43 cases), and interlaminar approach (40 cases) was used in group D (40 cases). There was no significant difference in gender, age, disease duration, symptomatic side, and segments among 4 groups ( P>0.05). The extirpation amount of nuclues pulposus was calculated and compared among 4 groups; the effectiveness was evaluated by pre- and post-operative visual analogue scale (VAS) score, Oswestry disability index (ODI), lumbar curvature index (LCI), and intervertebral height.

Results

The discectomy amount of nucleus pulposus was (3.7±0.8), (3.6±0.7), (4.5±1.1), and (3.0±0.8) cm ³ in groups A, B, C, and D, respectively. The amount of group C was significantly larger than that of the other 3 groups ( P<0.05), and the amount of group D was significantly smaller than that of the other 3 groups ( P<0.05); no significant difference was found between groups A and B ( P>0.05). Cerebrospinal fluid leakage was found in 1 case; no other postoperative complications including intervertebral space infection and epidural hematoma was found. All the incisions healed by first intension. All the patients were followed up 12-24 months (mean, 18 months), and no typical symptoms of recurrence was found during the follow-up period. There was no significant difference in preoperative lower back pain VAS score, lower extremities VAS score, and ODI scores among 4 groups ( P>0.05). The above scores at last follow-up were significantly improved when compared with preoperative ones in each group ( P<0.05), but no significant difference of above scores and recovery values was found among 4 groups ( P>0.05). The difference in LCI and intervertebral height at preoperation and at last follow-up were not significant between 4 groups ( P>0.05). The difference in LCI and intervertebral height of each group between at preoperation and last follow-up were not significant ( P>0.05). And the recovery value of LCI and the lost of height at last follow-up also showed no significant differences between 4 groups ( P>0.05).

Conclusion

The ITEA technology can give a wider field of view than other technologies. It is more convenient to find and remove the nucleus pulposus. However, the appropriate operative approaches should be chosen according to the symptoms and characteristics of lumbar disc herniation.

Preliminary results of lumbar disk herniation surgery by Endoscopic Destandau Method

BACKGROUND

The incidence of Disc herniation is about 2-3% of population. Each year 300,000 procedures performed in USA. The aim of this paper is to describe the utility of endoscopic procedure in treatment of lumbar disc herniation.

METHODS

We operated 359 patients from September 2013 to December 2016 for lumbar disk herniation by Endoscopic DESTANDAU method (EDM). The average length of surgery was 47 min. We operated 211 male and 148 female patients. In average, patients had pain for 4.3 months before surgery.

RESULTS

310 patients became pain free in six weeks and 332 after 3 months. We had 7 recurrent herniation. Among these patients 4 have been operated for the second time with success. Three patients refused to be operated. And had infiltration. We had 1 deep infection and 3 cutaneous infections. We have 7 two SCF fluid leak. Among them 3 needed second operation.

CONCLUSIONS

The patients are admitted the day of surgery and are discharged the day after surgery. EDM is a good alternative surgery for lumbar disk herniation in comparison with classical surgery. The duration of hospitalization is shorter and recovery is faster.