The role of transforaminal percutaneous endoscopic discectomy in lumbar disc herniations

Risk factors for lumbar disc herniation recurrence after percutaneous endoscopic lumbar discectomy: a meta-analysis of 58 cohort studies

Recurrent lumbar disc herniation (rLDH) is one of the most serious complications and major causes of surgical failure and paralysis following percutaneous endoscopic lumbar discectomy (PELD). There are reports in the literature on the identification of risk factors associated with rLDH; however, the results are controversial. Therefore, we conducted a meta-analysis to identify risk factors for rLDH among patients following spinal surgery. PubMed, EMBASE, and the Cochrane Library were searched without language restrictions from inception to April 2018 for studies reporting risk factors for LDH recurrence after PELD. MOOSE guidelines were followed in this meta-analysis. We used a random effects model to aggregate odds ratios (ORs) with 95% confidence intervals (CIs). The evidence of observational studies was classified into high quality (class I), medium quality (class II/III), and low quality (class IV) based on the P value of the total sample size and heterogeneity between studies. Fifty-eight studies were identified with a mean follow-up of 38.8 months. Studies with high-quality (class I) evidence showed that postoperative LDH recurrence after PELD was significantly correlated with diabetes (OR, 1.64; 95% CI, 1.14 to 2.31), the protrusion type LDH (OR, 1.62; 95% CI, 1.02 to 2.61), and less experienced surgeons (OR, 1.54; 95% CI, 1.10 to 2.16). Studies with medium-quality (class II or III) evidence showed that postoperative LDH recurrence was significantly correlated with advanced age (OR, 1.11; 95% CI, 1.05 to 1.19), Modic changes (OR, 2.23; 95% CI, 1.53 to 2.29), smoking (OR, 1.31; 95% CI, 1.00 to 1.71), no college education (OR, 1.56; 95% CI, 1.05 to 2.31), obesity (BMI ≥ 25 kg/m²) (OR, 1.66; 95% CI, 1.11 to 2.47), and inappropriate manual labor (OR, 2.18; 95% CI, 1.33 to 3.59). Based on the current literature, eight patient-related and one surgery-related risk factor are predictors of postoperative LDH recurrence after PELD. These findings may help clinicians raise awareness of early intervention for patients at high risk of LDH recurrence after PELD.

Safety and clinical efficacy of endoscopic procedures for the treatment of adjacent segmental disease after lumbar fusion: A systematic review and meta-analysis

BACKGROUND

Adjacent segment disease (ASD) is a common complication after lumbar fusion and is still traditionally treated by open surgery. In recent years, with the development of minimally invasive techniques, percutaneous endoscopic surgery(PES) has been used for the treatment of ASD after lumbar fusion due to its unique benefits. Nevertheless, it remains unclear about its significant clinical efficacy and advantages over conventional open surgery.

OBJECTIVES

To evaluate the clinical efficacy and safety of PES in the treatment of ASD after lumbar fusion.

STUDY DESIGN

A systematic review and meta-analysis studies about the role of PES in managing ASD after lumbar fusion.

METHODS

A systematic search review was conducted in PubMed, EMBASE, Cochrane Library, Web of Science, CNKI, VIP, WanFang, and SinoMed databases from the start of their construction to 15 November 2021. Eligible studies included references to clinical trials of PES for ASD after open lumbar fusion. Observations included pain relief, recovery of postoperative function, overall excellent rates, and indicators of the advantages of minimally invasive surgery compared to conventional surgery. Postoperative complications and recurrence rates were also recorded.

RESULTS

A total of 24 studies, including 20 single-arm studies and 4 clinical control studies, all involving 928 patients were included. A total of 694 patients were included in the single-arm analysis. The results of the single-arm meta-analysis showed that PES could significantly reduce low back and leg pain and improve the functional status of the lumbar spine in patients with ASD after open lumbar fusion compared to preoperatively, and had good clinical efficacy after surgery. A total of 234 patients were included in the four clinically controlled studies, and the results of the meta-analysis showed that PES could clearly reduce pain and improve lumbar function, with no significant difference in efficacy between PES and open surgery. However, PES has a lower surgical incision, less intraoperative bleeding, and shorter operative time and length of hospital stay compared to open surgery. Moreover, it has a lower rate of postoperative recurrence as well as complications and a longer duration of efficacy.

CONCLUSIONS

On the basis of the available clinical literature and the results of this study, PES could achieve satisfactory clinical effects in ASD treatment after lumbar fusion. Compared with conventional open surgery, PES can not only obtain similar clinical results, but also had the advantages of less trauma and faster recovery. Nevertheless, a randomized controlled study is still needed to validate the findings of this study.

TRIAL REGISTRATION

Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42022298387.

History of Endoscopic Spine Surgery in India

Endoscopic spine surgeries provide distinct advantages and is therefore a viable alternative to open or microscopic techniques. Indian surgeons have shown their expertise from craniovertebral junction to lumbosacral spine with these techniques. Many novel approaches like endoscopic transcervical, partial corpectomy, and others have been designed, and many technological innovations for these surgeries have been made. With different training programs attracting both native and international surgeons, the future of endoscopic spine surgery is bright.

Percutaneous transforaminal endoscopic discectomy for different types of lumbar disc herniation: A retrospective study

Objective

To introduce the concept of ‘nerve root as the core’ and to investigate the surgical procedure and curative effect of percutaneous translaminar endoscopic discectomy (PTED) surgery in the treatment of different types of lumbar disc herniation (LDH).

Methods

This retrospective study analysed the clinical data from patients with LDH that underwent single-segment PTED surgery. They were divided into three groups based on LDH location: central canal zone group, lateral recess zone group and foraminal/far lateral zone group. Different working cannula placement methods were used for the different types of LDH. All patients were followed for at least 12 months. Clinical and follow-up data were compared between the three groups.

Results

A total of 130 patients were enrolled in the study: 44 (33.8%) in the central canal zone group, 72 (55.4%) in the lateral recess zone group and 14 (10.8%) in the foraminal/far lateral zone group. All three groups of patients achieved good postoperative results. The improvements in leg pain and disability were most marked in the first postoperative month in all three groups.

Conclusion

PTED achieved adequate decompression for different types of LDH. The concept of ‘nerve root as the core’ facilitated the accurate placement of the working cannula.

Treatment of adjacent segment disease with percutaneous transforaminal endoscopic discectomy: Early experience and results

PURPOSE

Adjacent segment disease (ASD) constitutes a long-term complication of instrumented spinal fusion. Aim of this study is to analyze the utilization of percutaneous transforaminal endoscopic discectomy (PTED) for the treatment of symptomatic ASD, emphasizing basically in the postoperative course.

METHODS

A prospective study with 35 patients was designed. Patients enrolled in our study were distributed in two different groups. Group A constituted of 15 patients featuring ASD as a complication of a previously conducted lumbar spinal fusion. Group B was composed of 20 patients, presenting simple lumbar disc herniation (LDH). All patients were subjected to successful PTED for LDH. Patients were evaluated at regular intervals in 6-week and 3-, 6-, and 12-month postoperatively. Visual analog scale was utilized for leg (VAS-LP) and low back pain (VAS-BP) evaluation. Health-related quality of life was assessed with short-form 36 health survey questionnaire (SF-36).

RESULTS

VAS-BP scores were statistically significantly differentiated between the two groups in all intervals of follow-up. In contrast, VAS-LP scores demonstrated statistically significant differentiation in none of follow-up intervals, indicating similar results between the two groups. Maximal improvement was in both cases for all patients observed in 6-week postoperatively, with subsequent stabilization. SF-36 preoperative evaluation denoted a statistically significant differentiation in bodily pain and role emotional parameters, which was continually until the end of follow-up observed. The other SF-36 parameters featured similar values between the two groups preoperatively as well as during the follow-up intervals.

CONCLUSION

PTED is capable of successfully dealing with LDH and furthermore with complications of fusion as ASD.

Percutaneous endoscopic lumbar discectomy for lumbar disc herniation as day surgery - short-term clinical results of 235 consecutive cases

Many studies have reported the good outcomes of percutaneous endoscopic lumbar discectomy (PELD) for the treatment of lumbar disc herniation (LDH). However, the majority of published studies on PELD showed an average hospital stay of 2 to 5 days. Thus, the purpose of this retrospective study was to evaluate and compare the clinical outcomes of patients undergoing PELD for LDH as day surgery with the outcomes of patients managed as inpatients.A total of 402 patients who underwent PELD for single-level LDH were included. The visual analog scale score (VAS) for leg and back pain, Oswestry Disability Index (ODI) score, and Macnab criteria were evaluated preoperatively and at 2 years postoperatively (final follow-up). Operation time, duration of hospital stay, cost, postoperative complications, and the rates of and reasons for delayed discharge and readmission were recorded and analyzed.The mean operative time was 45.8 ± 8.4 minutes in the PELD-A (nonday surgery mode) group and 41.3 ± 8.7 minutes in the PELD-D (day surgery mode) group (P = .63). The average duration of hospital stay was 2.8 ± 1.1 days in the PELD-A group and 3.2 ± 0.9 hours in the PELD-D group (P < .001). The average hospitalization expenses of the PELD-A and PELD-D groups were 28,090 ± 286 RMB and 24,356 ± 126 RMB (P = .03), respectively. In both groups, the mean VAS and ODI scores improved significantly postoperatively compared with the preoperative scores. The satisfactory result rate was 89.8% in the PELD-D group and 91.0% in the PELD-A group, without a significant difference (P = .68). The delayed discharge rate in the PELD-A and PELD-D groups was 8.20% and 8.43%, respectively (P = .93). The main reasons for delayed discharge were dysesthesia, neurologic deficit, nausea, headache and residential distance from the hospital. The overall readmission rates were 5.99% and 5.53% in the PELD-A and PELD-D groups, respectively (P = .85). The most common reasons for readmission were reherniation, sequestered herniation and pain.In conclusion, PELD is safe and effective for the treatment of LDH and can reduce medical costs as day surgery, and it thus warrants increased attention.

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 Mobile Outside-in Technique of Transforaminal Lumbar Endoscopy for Lumbar Disc Herniations

Percutaneous endoscopic transforaminal lumbar discectomy (PETLD) has now become a standard of care for the management of lumbar disc disease. There are two techniques for the introduction of a working cannula with respect to disc-outside-in and inside-out. The aim of this prospective study is to describe the technical aspects of a novel mobile outside-in method in dealing with different types of disc prolapse. A total of 184 consecutive patients with unilateral lower limb radiculopathy due to lumbar disc prolapse were operated on with the mobile outside-in technique of PETLD. Their clinical outcomes were evaluated based on the type of disc prolapse they had, a visual analog scale (VAS) leg pain score, the Oswestry Disability Index (ODI), and the Macnab criteria. The completeness of the decompression was documented with a postoperative magnetic resonance imaging. The mean age of the patients was 50 ± 16 years and the male/female ratio was 2:1. The mean follow-up was 19 ± 6 months. A total of 190 lumbar levels were operated on (L1-L2: n = 4, L2-L3: n = 17, L3-L4: n = 27, L4-5: n = 123, and L5-S1: n = 19). Divided into types, the patient distribution was central: n = 14, paracentral: n = 74, foraminal: n = 28, far lateral: n = 13, superior-migrated: n = 8, inferior migrated: n = 38, and high canal compromise: n = 9. The mean operative time was 35 ± 12 (25 - 56) min and the mean hospital stay was 1.2 ± 0.5 (1-3) days. The VAS score for leg pain improved from 7.5 ± 1 to 1.7 ± 0.9. The ODI improved from 70 ± 8.3 to 23 ± 5. According to the Macnab criteria, 75 patients (40.8%) had excellent results, 104 patients (56.5%) had good results, and 5 patients (2.7%) had fair results. Recurrence (including early and late) was seen in 15 out of the 190 levels that were operated on (7.89%). This article presents a novel outside-in approach that relies on a precise landing within the foramen in a mobile manner and does not solely depend upon the enlargement of the foramen. It is more versatile in application and useful in the management of all types of disc prolapse, even in severe canal compromise and high migration.

Therapeutic effect of percutaneous endoscopic lumbar discectomy on lumbar disc herniation and its effect on oxidative stress in patients with lumbar disc herniation

This study investigated the therapeutic effect of percutaneous endoscopic lumbar discectomy on lumbar disc herniation, and explored its effect on oxidative stress in patients with lumbar disc herniation. One hundred and ten patients with lumbar disc herniation were selected in The Affiliated People's Hospital of Shanxi Medical University from May 2015 to May 2016. Patients were divided into control group (n=50) and observation group (n=60) according to different surgical methods. Patients in control group were subjected to traditional open discectomy, while patients in observation group were treated with percutaneous endoscopic lumbar discectomy. Surgical-related indicators, ODI and VAS scores before and 3 months after surgery, serum inflammatory factors and oxidative stress indicators were compared between 2 groups. There was no significant difference in operation time between the groups. Blood loss, incision size and time of bed rest in observation group were better than those in control group (P<0.05). Compared with preoperative levels, ODI and VAS scores of the two groups were significantly reduced at 3 months after surgery, but the scores of observation group were significantly higher than those of control group (P<0.05). There were no significant differences in the levels of serum inflammatory factors TNF-α and CRP and oxidative stress indicators MDA, MPO, SOD and TAC between the two groups before surgery (P>0.05). Levels of serum inflammatory factors TNF-α and CRP and oxidative stress indicators MDA and MPO were significantly lower and levels of oxidative stress indicators SOD and TAC were significantly higher in observation group than in control group (P<0.05). Therefore, treatment of lumbar disc herniation with percutaneous endoscopic lumbar discectomy has the advantages of small trauma, less blood loss and fast recovery, and can effectively improve the dysfunction, reduce pain and serum levels of inflammatory factors, and improve the levels of oxidative stress indicators, thereby improving the surgical results. Thus, this method should be considered for wide-use.

Analysis of Clinical Results of Three Different Routes of Percutaneous Endoscopic Transforaminal Lumbar Discectomy for Lumbar Herniated Disk

OBJECTIVE

Percutaneous endoscopic transforaminal lumbar discectomy (PETLD) can be performed by using foraminal, intervertebral, and suprapedicular routes. The aim of this study was to assess clinical results of three different routes of PETLD.

METHODS

One hundred eleven patients who underwent PETLD between January 2016 and October 2016 were included in this study. PETLD was performed using the foraminal (group A), intervertebral (group B), and suprapedicular (group C) routes in 32, 46, and 33 patients, respectively. Outcomes were evaluated using the visual analogue scale (VAS), Oswestry Disability Index (ODI), and MacNab criteria.

RESULTS

Seventy-one men and 40 were women (mean age 53.33 ± 14.12 years). The mean follow-up period was 6.44 ± 3.26 months. The preoperative VAS score decreased significantly (P < 0.01) in all 3 groups, but the postoperative VAS score was higher for the foraminal route than for the intervertebral (P = 0.001) and suprapedicular routes (P < 0.001). Excellent outcome grade according to MacNab criteria was less in foraminal route (18.7%) than in intervertebral (52.2%) and suprapedicular (56.7%) routes. ODI improved significantly (P < 0.01) in all 3 groups.

CONCLUSION

All 3 routes of PETLD resulted in good to excellent clinical results. Nevertheless, the postoperative VAS score was higher for the foraminal route than for the intervertebral and suprapedicular routes, probably not because of the surgery but because of the neurologic characteristics of the disk location. The surgeon should consider this problem to alleviate pain postoperatively and counsel to patient well before surgery.