Revisional percutaneous full endoscopic disc surgery for recurrent herniation of previous open lumbar discectomy. Asian Spine J. 2011;5:1-9. [PMID: 21386940 PMCID: PMC3047892 DOI: 10.4184/asj.2011.5.1.1]

Clinical Effects of the End-Love Technique in the Treatment of Recurrent Lumbar Disc Herniation 1 Year After Surgery

Background

The number of patients with lumbar disc herniation in China is increasing year by year. Percutaneous endoscopic lumbar discectomy (PELD) is currently the main surgical method for treating lumbar disc herniation (LDH). However, with the increase in the number of surgical cases, the number of patients with recurrent lumbar disc herniation (RLDH) is also increasing. Currently, the common method in China is lumbar fusion surgery, but this surgery would cause the loss of fusion segment mobility and considerable postoperative complications. In order to solve the problem above the following technique will be studied: the technique of posterior lumbar laminectomy and nucleus pulposus removal under fully visualized spinal endoscopy (ENDO-LOVE) to treat RLDH. Its clinical effects will be observed in this paper, too.

Methods

This series includes RLDH patients treated with ENDO-LOVE technology between January 2017 and January 2021. All patients will undergo at least three follow-up visits one year after surgery. The modified MacNab standard, VAS, JOA, and ODI scores will be used to evaluate clinical efficacy, observe for cerebrospinal fluid leak, nerve root injury, and surgical site infection, and evaluate clinical safety.

Results

All 29 patients completed the surgery successfully. Three patients had postoperative pain and numbness in the area of nerve root innervation, and all patients had no serious complications. The VAS, JOA scores and ODI indices of back pain and leg pain 1-day, 3-months, and 1-year postoperatively differed statistically significantly from the preoperative scores (p < 0.05). Efficacy evaluated at 1-year postoperatively using the modified MacNab criteria showed an excellent rate of 89.7%.

Conclusion

ENDO-LOVE technology has demonstrated good clinical efficacy and safety in the treatment of patients with RLDH. It should be considered for all patients with this condition.

Functional Outcomes After Discectomy for Recurrent Lumbar Herniation Using the Destandau Endospine System: A Retrospective Study of 44 Patients

Background Recurrent disc herniation is a major cause of morbidity and surgical failure after disc surgery. This study aimed to investigate the feasibility, safety, and effectiveness of the Destandau endospine system (DES) for treating recurrent lumbar disc herniation (LDH). Methodology A total of 44 patients who underwent minimally invasive Destandau endoscopic lumbar discectomy (DELD) for recurrent LDH were included in this study. All data were collected retrospectively. The preoperative and postoperative visual analog scale (VAS) score was used for the evaluation and gradation of pain. The clinical outcome was analyzed according to modified MacNab criteria. The minimum follow-up was two years. Preoperative and postoperative VAS scores were compared using the paired Student's t-test. Statistical significance was set at a p-value <0.05. Results The mean surgical time was 30 ± 20 minutes. The VAS score for leg pain was improved in all cases from 5.9 ± 2.1 to 1.7 ± 1.3 (p< 0.001). In 98% of cases, a successful outcome was noted (excellent or good outcome according to MacNab criteria). In three (7%) patients, incidental durotomy occurred, but there was no neurological worsening, cerebrospinal fluid fistula, or negative influence on the clinical outcome. No recurrence or instability occurred in our series. Conclusions The clinical outcomes of minimally invasive DES for LDH were found to be comparable with the reported success rates of other minimally invasive techniques reported in the existing literature. The dural tear rate was independent of postoperative morbidity and functional outcome. The technique is a safe and effective treatment option for recurrent LDH.

The effect of annulus fibrosus incision and foraminoplasty on lumbar biomechanics in percutaneous endoscopic lumbar discectomy: a finite element analysis

The objective of this study was to analyze the effects of annulus fibrosus incision and foraminoplasty on lumbar biomechanics during posterior lateral approach translaminar percutaneous endoscopic lumbar discectomy (PELD) using a lumbar 4/5 segment model and three-dimensional finite element analysis (FEA). We created a model of the L4 to L5 segment and performed simulated foraminoplasty, annulus fibrosus incision, and a combined operation. The models were tested under six working conditions, and we recorded the deformation and equivalent strain/stress of each group. Results showed that foraminoplasty can affect the stability and rotation axis of the segment during rotation without significantly impacting discal stress. Conversely, annulus fibrosus incision significantly increases discal stress except for when the patient is doing a forward flexion movement. We recommend that surgical maneuvers minimize the removal and destruction of the annulus fibrosus and that rotation movements are avoided during the short-term recovery period following PELD surgery.

Surgical Strategy and Outcomes of Full Endoscopic Lumbar Discectomy for Recurrent Lumbar Disk Herniation Following a Previous Full Endoscopic Lumbar Discectomy

OBJECTIVE

Recurrent lumbar disc herniation (RLDH) cannot be prevented after full endoscopic lumbar discectomy (FELD), and the optimal surgical treatment for RLDH after FELD remains controversial. The aim of the study was to suggest a surgical strategy for FELD to treat RLDH following a previous FELD and to present surgical outcomes.

METHODS

Between February 2015 and March 2022, 68 patients with RLDH were surgically treated with FELD retrospectively. An original approach was suggested for the treatment of early recurrence (24 h-2 weeks). The full endoscopic transforaminal technique (FETD) was considered for patients requiring local anesthesia, and in RLDH with FETD indications or FEID technological difficulties. The full endoscopic interlaminar technique (FEID) was chosen in RLDH with FEID indications. Both FEID and FETD were suitable if no FEID or FETD technological difficulties existed. Clinical efficacy was evaluated using the visual analog scale (VAS) score, Oswestry disability index (ODI), and modified MacNab criteria. Postoperative follow-up data at 24 h, 3 months, and final-follow-up were recorded. Operation time and clinical outcomes were assessed with t test. p-value < 0.05 was considered statistically significant.

RESULTS

All 68 patients had an average follow-up time of 23.8 months (range, 6-76 months). In the 13 cases of early recurrence, the operation time (32.30 ± 9.67 vs. 58.00 ± 6.16 min) in the original surgical approach group was shorter than that in the changing surgical approach group (p < 0.05). In the 28 cases of L4/5 FETD recurrence (>2 weeks), the operation time (66.17 ± 12.18 vs. 53.60 ± 5.45 min) in the FETD group was more than that in the FEID group (p < 0.05). In the 22 cases of L5S1 recurrence (>2 weeks), the operation time (55.75 ± 8.79 vs. 79.33 ± 6.65 min) in the FEID group was shorter than in the FETD group (p < 0.05). The postoperative VAS and ODI scores at 24 h, 3 months, and final-follow up were all significantly improved, compared with their preoperative counterparts (p < 0.05). Based on the modified MacNab criteria, 88.23% of patients showed excellent or good results. Re-recurrence occurred in three patients at 3 months. No surgical complications were observed in any of the 68 cases.

CONCLUSION

FELD is a safe and effective treatment option for RLDH with previous FELD. For early recurrence, the original approach was suggested. Both FEID and FETD were effective and safe for recurrence (>2 weeks), but FEID seemed more efficient for L4/5 RLDH after previous FETD and for L5S1 RLDH.

Comparison of Primary Versus Revision Lumbar Discectomy Using a Biportal Endoscopic Technique

STUDY DESIGN

Retrospective study.

OBJECTIVE

To compare the clinical outcomes of the biportal endoscopic technique for primary lumbar discectomy (BE-LD) and revision lumbar discectomy (BE-RLD).

METHODS

Eighty-one consecutive patients who underwent BE-LD or BE-RLD, and could be followed up for at least 12 months were divided into two groups: Group A (BE-LD; n = 59) and Group B (BE-RLD; n = 22). Clinical outcomes included the visual analog scale (VAS), Oswestry Disability Index (ODI), and modified MacNab's criteria. Perioperative results included operation time (OT), length of hospital stay (LOS), amount of surgical drain, and kinetics of serum creatine phosphokinase (CPK) and C-reactive protein (CRP). Clinical and perioperative outcomes were assessed preoperatively and postoperatively at 2 days and at 3, 6, and 12 months. Postoperative complications were noted.

RESULTS

Both groups showed significant improvement in pain (VAS) and disability (ODI) compared to baseline values at postoperative day 2, which lasted until the final follow-up. There were no significant differences in the improvement of the VAS and ODI scores between the groups. According to the modified MacNab's criteria, 88.1 and 90.9% of the patients were excellent or good in groups A and B, respectively. OT, LOS, amount of surgical drain, and kinetics in serum CRP and CPK levels were comparable. Complications in Group A included incidental durotomy (n = 2), epidural hematoma (n = 1), and local recurrence (n = 1) and in Group B incidental durotomy (n = 1) and epidural hematoma (n = 1).

CONCLUSION

BE-RLD showed favorable clinical outcomes, less postoperative pain, and early laboratory recovery equivalent to BE-LD.

Tubular Microdiscectomy for Recurrent Lumbar Disc Herniation: A Valuable Alternative to Endoscopic Techniques

OBJECTIVE

The efficacy of tubular microdiscectomy (TMD) in the treatment of recurrent lumbar disc herniation (rLDH) is still unclear, especially compared with the endoscopic technique. We performed a retrospective study to analyze this question.

METHODS

We retrospectively included all patients with an rLDH confirmed by magnetic resonance imaging who underwent TMD between January 2012 and February 2019. The general data included sex, age, body mass index, level of rLDH, first surgical approach, reoperation interval, occurrence of dural leak, re-recurrence, and re-reoperation. The clinical outcome was evaluated using a visual analog scale for leg pain, and the modified MacNab criteria were used to evaluate patient satisfaction.

RESULTS

The visual analog scale score for leg pain was statistically significantly reduced from 7.46 preoperatively to 0.80 postoperatively (P < 0.00001), and the patient satisfaction was good or excellent in 85.7% of cases, according to the modified MacNab criteria. Complications occurred in 3 of the 15 included patients: 2 dural tears (13.3%) and 2 re-recurrence (13.3%), but none of the patients underwent a third surgical procedure.

CONCLUSIONS

TMD seems to be an efficient technique for the surgical treatment of leg pain caused by rLDH. In the literature, this technique seems to be at least as good as the endoscopic technique and is easier to master.

Percutaneous Endoscopic Lumbar Discectomy for Recurrent Lumbar Disc Herniation: An Updated Systematic Review and Meta-Analysis

OBJECTIVE

This meta-analysis evaluated surgical outcomes following endoscopic or conventional discectomy for recurrent lumbar disc herniation.

METHODS

Medline, Cochrane, EMBASE, and Google Scholar were search until October 16, 2016 using these terms: recurrent lumbar disc herniation, endoscopic surgery, and discectomy. Randomized controlled trials (RCTs), prospective, retrospective, and cohort studies were eligible for inclusion. Pooled difference in mean (PDM) with 95% confidence interval (CIs) or relative risks (RRs) were calculated using fixed-effects methods.

RESULTS

One RCT and 15 studies were included with a total of 820 patients. Patients received endoscopic surgery experienced shorter operation time than those received conventional surgery (PDM: -52.01, 95% CI: -76.84 to -27.18, P < 0.001). A significantly lower risk in complication was displayed in patients received endoscopic surgery compared to those received conventional surgery (RR: 0.209, 95% CI: 0.076-0.581, P = 0.003). No significant difference in the improvement in VAS (PDM: -2.19, 95% CI: -5.78 to 1.39, P = 0.231), length of stay (PDM: -6.44, 95% CI: -13.76 to 0.89, P = 0.085) and re-recurrence rate (PDM: 0.88, 95% CI: 0.22-3.50, P = 0.861) between groups.

CONCLUSIONS

Endoscopic and conventional discectomy reduced patient pain comparably, but endoscopic discectomy had significantly lower operation time and lower risk in complications, which may impact other outcomes such as recovery and healthcare costs. More studies are needed to confirm our findings.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-022-00636-1.

Ultrasound Lancet-aided Translaminar Posterior Lumbar Approach to the Recesso-Foraminal Area: Technical Note

Extrusion and sequestration of the nucleus pulposus involving the spinal canal or the foramina/recesses complicates up to 28% of the lumbar disc herniations. The transpars/translaminar anatomical approach is well described and its advantages when handling with a lateral, foraminal extruded disc herniation are appreciated and recognized. Nevertheless, this approach presents several pitfalls such as the risk of disconnecting the pars interarticularis, which may cause segmental instability. This particular eventuality is because of the particular anatomical conformation of the pars interarticularis. Although already part of the modern surgical armamentarium for general, orthopedic, cranial and spinal surgeons, the use of the ultrasonic scalpel technique for such approach has never been discussed to date, to the best of our knowledge. The purpose of the present paper is therefore to introduce and describe the stepwise technique along with an extensive discussion of the facilitating role of the ultrasonic scalpel in the translaminar/transpars approach in the management of extruded disc herniation of the lumbar spine.

Neurological safety of spinal surgery for nucleus pulposus removal under spinal endoscopic imaging guided by inter laminar spine

Objective

To explore the technical points, approach selection and short-term clinical efficacy of PELD through the intervertebral foramina or interlaminar approach in the treatment of highly shifted LDH.

Methods

From September 2018 to June 2020, 19 patients with highly shifted LDH were treated with PELD in The First Hospital of Yulin. It included, 10 males and 9 females; aged 34 to 69 years, with an average of 48 years. Thirteen cases were shifted to the caudal side, and six cases were shifted to the head side. The responsible segments included L3/41 cases, L4/511 cases, and L5/S17 cases. All patients had symptoms of low back and leg pain. The Sowerby dysfunction index (ODI) was 63.5%±10.7% before surgery. The visual analogue scale of pain (VAS) was low back pain (5.2±2.1) and leg pain (7.1±2.4). 14 cases used transforaminal approach, and 5 cases used translaminar approach.

Results

All cases completed the operation successfully, the operation time was 60~110min, with an average of 70 minutes. The follow-up time ranged from 6 to 42 months, with an average of 20.8 months. At the last follow-up, ODI was 10.8%±6.8%, VAS back pain score (2.1±1.1) and leg pain score (1.8±0.9). Compared with preoperative, ODI and VAS scores were significantly decreased (P<0.05). The results of Mac Nab method were 14 excellent, four good, and one fair. During the follow-up period, one patient's leg pain symptoms recurred seven days after operation. No further hernia was found under intervertebral foramen. The symptoms disappeared after two weeks of symptomatic treatment such as swelling and analgesia, and he was discharged. No perioperative complications such as infection and nerve root injury occurred.

Conclusion

When PELD is used to treat high-displacement LDH, the choice of transforaminal approach or interlaminar approach needs to be personalized according to the LDH segment and the direction of displacement.

Full-Endoscopic Lumbar Discectomy for Recurrent Lumbar Disc Herniation: A Retrospective Study with Patient-Reported Outcome Measures

Introduction

Revision surgery for recurrent lumbar disc herniation after surgical treatment is at times challenging due to epidural adhesions and scar. This study aimed to review the clinical results and safety of full-endoscopic lumbar discectomy via interlaminar (FELD-IL) and transforaminal (FELD-TF) approaches for revision surgery.

Methods

We conducted a retrospective study including 52 lumbar disc herniation revision patients (mean age, 51.8 years; male/female, 13/39), with 17 FELD-IL and 35 FELD-TF cases. Complication incidences were assessed by reviewing surgical videos and postoperative magnetic resonance images of nerve decompression outcomes. Patients' responses to Japan Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) and numerical rating scales (NRS) for lumbar pain, leg pain, and leg numbness were recorded before and during follow-up. The Wilcoxon-signed rank tests were utilized to compare pre- and postoperative group variables.

Results

The average operation time was 33.0 min in FELD-IL and 31.7 min in FELD-TF. Seven FELD-IL cases required lamina excavation with high-speed drill bars for scar tissue dissection from the lamina. Dura injury occurred during the excavation in one case. No complication was noted in the FELD-TF group. Successful decompression of the nerve was achieved in all cases. Complete sets of JOABPEQ and NRS were obtained in 64.5% of FELD-IL and in 82.9% of FELD-TF. The mean follow-up period was 18.6 months. All the subdomain of JOABPEQ and NRS improved significantly postoperative in both groups. There was no difference regarding the improvement of scores between the procedures except NRS for lumbar pain, which was more favorable in FELD-IL. Recurrence of herniation occurred in one patient (6%) after FELD-IL and two patients (6%) after FELD-TF.

Conclusions

Both FELD-IL and FELD-TF are safe and effective revision procedures for recurrent lumbar disc herniation. FELD-TF could be performed employing the same procedure as primary surgery in revisions, regardless of the previous surgical approach.

[Analysis of surgical strategy of percutaneous endoscopic lumbar discectomy in young and middle-aged double-segment patients with lumbar disc herniation]

OBJECTIVE

To investigate clinical efficacy and safety of single and double segmental percutaneous lumbar discectomy for young and middle-aged patients with double-segment disc herniation.

METHODS

Retrospective analysis was undertaken for 32 young and middle-aged patients with percutaneous endoscopic lumbar discectomy (PELD) in the treatment of double-segment lumbar disc herniation from January 2015 to October 2018 in Peking University First Hospital. In the study, 18 cases were treated with single-segment treatment and 14 cases with double-segment treatment. Visual analogue score (VAS) and oswestry disability index (ODI) assessment were used to compare clinical symptom outcomes before surgery, 3 months after surgery and at the last follow-up. Macnab criteria were used to assess the patients' overall satisfaction after surgery. Imaging parameters included lumbar lordosis, intervertebral height at each segment and endplate angle of lesion segment on the X-ray. And Michigan State University(MSU) rating and Pfirrmann scoring system were used to evaluate the grade of disc herniation and disc degeneration respectively on magnetic resonance imaging (MRI). The perioperative parameters included the surgeon, anesthesia method, operation time, postoperative hospital stay, postoperative bracing time and perioperative complications.

RESULTS

The mean follow-up time was (26.78±10.64) months. There was no significant difference in the follow-up time and baseline information between the two groups(P > 0.05). ODI scores 3 months post-operatively and at the last follow-up were lower in the double segment (P < 0.05). The ODI improvement was also more significant in the double-segment group at the last follow-up (P < 0.05). There was no significant difference in radiographic parameters at baseline (P>0.05). MSU scale for the primary segment was significantly lowered after both operations (P < 0.05). MSU scale for secondary segment was significantly lowered in double segment group but not in single segment group. Other imaging parameters were similar between the two groups (P > 0.05). The operation time of the single-segment group was significantly shorter than that of the double-segment group(P < 0.001). No perioperative complications were found in either group, but three patients underwent secondary lumbar surgery during the postoperative follow-up period in the single-segment group.

CONCLUSION

For young and middle-aged patients with double-segment disc herniation, this study suggests double-segment PELD may be more advantageous than single-segment PELD in terms of asuring clinical efficacy without increasing perioperative risks.

Endoscopic interlaminar lumbar discectomy: How to decrease the learning curve

Background:

Herniated lumbar disc is a common cause of lumbosacral pain. Endoscopic interlaminar lumbar discectomy (ILD) is a well-established technique that provided comparable results to micro-discectomy. The aim of the study is to describe the learning curve of endoscopic ILD and explore measures that could improve effectiveness and decrease blood loss and operative time with accumulation of reasonable experience.

Methods:

This retrospective cohort study included 65 patients presenting with symptomatic herniated lumbar disc who underwent endoscopic ILD. Patients were divided into two groups: Group I (standard technique) and Group II (modified technique). Collected data included patients’ age, gender, preoperative manifestations, visual analog score (VAS) for pain, Oswestry Disability Index (ODI), disc level, operative time, intraoperative blood loss, complications, and follow-up data at 1, 6, and 12 months postoperatively. Primary outcomes included total operative time, amount of intraoperative blood loss, and post-operative improvement in pain. Secondary outcomes included intraoperative complications, rate of conversion to open surgery, and recurrence.

Results:

Post-operative VAS and ODI improved significantly in both groups. Mean total surgical time and intraoperative blood loss were significantly lower in Group II compared to Group I (P < 0.001). The learning curves for operative time and intraoperative blood loss were shallow in Group I, and almost flattened in Group II. Complications were recorded in only three cases, and no symptomatic recurrences were reported.

Conclusion:

The learning curve of endoscopic ILD was shallow with standard technique, indicating difficulties in mastering the procedure. The proposed modified technique helped reaching the required level of proficiency in the early phase of the curve, providing a significant reduction in operative time and blood loss, with comparable effectiveness and safety as the standard technique.

Full endoscopic interlaminar discectomy (FEID) for recurrent lumbar disc herniation: surgical technique, clinical outcome, and prognostic factors

Background

The objective of this study is to determine the effectiveness and prognostic factors of revisional full endoscopic interlaminar discectomy (FEID) for recurrent herniation after conventional open disc surgery. The major concerns of the repeated discectomy for recurrent lumbar disc herniation (RLDH) are the epidural scar and postoperative segmental instability. Compared to open discectomy, endoscopic method has advantages of less tissue traumatization, clearer visualization and better tissue identification. With the improvement of endoscopic technique and instrument, the problems related to adhesive scar tissues or postoperative instability could be overcome.

Methods

From June 2014 to December 2016, FEID was performed in consecutive 24 patients for RLDH. The age ranged from 25 to 60 years (mean 44.6 years). The level operated was L5-S1 in 16 cases and L4-5 in 8 cases. To avoid injury to the neural tissue, we started with the bony structure. A small part of facet or lamina might be resected in severe stenotic or adhesive condition. Aggressive separation of the scar from the neural tissue might lead to dural tear and should be avoided. The herniated disc material was removed after neural tissue had been clearly identified and protected.

Results

The follow-up period was at least 24 months. The visual analog scale (VAS) for leg pain and back pain, and Oswestry disability index (ODI) showed significant improvement after treatment. Excellent or good outcome by the modified Macnab's criteria was obtained in 22 of 24 patients at two years follow-up. Excellent outcome was noted in 100 percent patients younger than 50 years. Small durotomy occurred in 2 patients and no visible cerebrospinal fluid (CSF) leakage was detected despite repair was not performed. Two additional surgery was performed including one repeated FEID for re-recurrence of disc herniation and one fusion surgery for postoperative back pain.

Conclusions

FEID is a safe and effective alternative for recurrent disc herniation. The successful rate was greater than 90 percent, especially in the younger patients with the advantages of early recovery and no need for fusion.

Is fusion the most suitable treatment option for recurrent lumbar disc herniation? A systematic review

OBJECTIVE

Recurrent lumbar disc herniation (rLDH) is a common issue after primary discectomy and can cause severe pain, morbidity, and reoperation. The purpose of this systematic review was to evaluate the surgical management of recurrent lumbar disc herniation.

METHODS

A systematic literature search was conducted using Pubmed and Embase databases on 18^thAugust, 2019. The inclusion and exclusion criteria were applied according to study design, surgical approach, language, number of patients; and spinal level. Data extracted included patient demographics, and clinical outcomes (patients with excellent/good outcomes; VAS back and leg score improvement, complication and recurrence rates).

RESULTS

Sixteen studies, (comprising of seven prospective and nine retrospective) met the inclusion criteria. Ten studies evaluated discectomy only; four analysed fusion, and two analysed both discectomy only and fusion approaches. Fusion approaches recorded a superior success rate (8.3 % higher, p>0.05); postoperative VAS back score improvement (5 % higher, p>0.05) than discectomy alone.  However, discectomy alone approaches recorded a more favourable postoperative VAS leg score improvement (4.2 % higher p>0.05), and complication rate (3.2% lower, p>0.05) than fusion techniques.

CONCLUSION

There is significant heterogeneity in clinical outcomes reported for studies after surgical intervention in rLDH patients. Neither discectomy nor fusion's superiority was statistically significant. Despite fusion yielding longer operative times, and length of stay (adding to the expense), it is superior in minimising mechanical instability and recurrence. Finally, we conclude that both approaches are equally efficacious in rLDH cases, and choice should be based on a case by case basis.

Risk Factors and Surgical Treatment for Recurrent Lumbar Disc Prolapse: A Review of the Literature

We aim to present the current evidence on various risk factors and surgical treatment modalities for recurrent lumbar disc herniation (rLDH). Using PubMed, a literature search was performed using the Mesh terms "recurrent disc prolapse," "herniated lumbar disc," "risk factors," and "treatment." Articles that were published between January 2010 and May 2017 were selected for further screening. A search conducted through PubMed identified 213 articles that met the initial screening criteria. Detailed analyses showed that 34 articles were eligible for inclusion in this review. Sixteen articles reported the risk factors associated with rLDH. Decompression alone as a treatment option was studied in seven articles, while 11 articles focused on different types of fusion surgery (anterior lumbar interbody fusion, posterior lumbar interbody fusion, open transforaminal lumbar interbody fusion [TLIF], and minimally invasive surgery-TLIF). Management of the rLDH requires consideration of the possible risk factors present in individual patients before primary and at the time of second surgery. Both, minimally invasive and conventional open procedures are comparably effective in relieving leg pain, and minimally invasive techniques offer advantage over the other technique in terms of tissue sparing. Non-fusion surgeries involve the risk of lumbar disc herniation re-recurrence, and the patient may require a third (fusion) surgery.

Longitudinal clinical outcomes after full-endoscopic lumbar discectomy for recurrent disc herniation after open discectomy

OBJECTIVE

Full-endoscopic lumbar discectomy (FELD) is a minimally invasive surgical option for recurrent lumbar disc herniation (LDH). Nonetheless, patients' clinical outcomes may be poorer after surgery for recurrent LDH than for primary LDH. Therefore, we compared patients' longitudinal clinical outcomes after FELD for recurrent LDH or primary LDH.

METHODS

The medical records of patients who underwent FELD for primary LDH (group A) or recurrent LDH (group B) were retrospectively reviewed. The inclusion criteria were: 1) single-level LDH or recurrent LDH at L4-5 or L5-S1, 2) age ≤60 years, 3) previous open discectomy (group B), and 4) ≥6 months of follow-up. In total, 244 patients (group A, 211; group B, 33) were included. Clinical outcomes (Oswestry Disability Index [ODI]; visual analogue pain score for the back and leg [VAS-B] and [VAS-L]) over 24 months of follow-up were compared between groups with a linear mixed-effects model.

RESULTS

All clinical outcomes significantly improved from pre-operation to 3 months postoperatively (p < 0.01), and the improvement was maintained for 24 months postoperatively in both groups. The clinical outcomes of groups A and B were not significantly different during 24 months follow-up (ODI, p = 0.94; VAS-B, p = 0.11; and VAS-L, p = 0.48). The reoperation rate was 3.3% in group A and 3.0% in group B, but the overall complication rate was higher in group B (9.8%) than in group A (6.6%).

CONCLUSION

The longitudinal clinical outcomes after FELD for recurrent LDH may not be poor as feared. However, the higher complication rate in patients undergoing FELD for recurrent LDH should be noted.

The Role of Full-Endoscopic Lumbar Discectomy in Surgical Treatment of Recurrent Lumbar Disc Herniation: A Health-Related Quality of Life Approach

Objective

To investigate the utility of full-endoscopic lumbar discectomy (FELD) in surgical treatment of recurrent lumbar disc herniation (RLDH).

Methods

Forty-five patients were prospectively studied. All patients were subjected to FELD for RLDH. They were assessed preoperatively and in regular intervals at 6 weeks and 3 months, 6 months, and 12 months postoperatively. Evaluation was conducted with visual analogue scale for leg (VAS-LP) and low back (VAS-BP) pain. Short-Form 36 Health Survey Questionnaire was utilized for health-related quality of life assessment.

Results

All studied parameters featured statistically significant amelioration at all follow-up intervals. Maximal improvement was in general at 6 weeks observed, with subsequent lesser improvement until 6 months and stabilization until the end of follow-up. Comparative assessment indicated that VAS-BP displayed quantitatively lower improvement, whereas physical function, bodily pain, and role-emotional parameters demonstrated greater amelioration.

Conclusion

FELD is associated with a favorable impact in postoperative daily life of patients with RLDH.

Surgical Treatment of Recurrent Lumbar Disk Herniation: A Systematic Review and Meta-analysis

Consensus is lacking regarding optimal surgical treatment of recurrent lumbar disk herniation. A systematic search of multiple databases was conducted for studies evaluating outcomes after treatment for recurrent lumbar disk herniation. Treatment options included decompression surgeries and fusion surgeries. Although fusion surgeries eliminated re-recurrence of disk herniation, this coincided with higher incidences of complications and reoperation. Decompression surgeries and fusion surgeries both resulted in improvements in Japanese Orthopaedic Association, Oswestry Disability Index, and visual analog scale back and leg scores postoperatively (P<.05). The complication risk profiles of decompression surgeries and fusion surgeries must be balanced with the risk of disk herniation re-recurrence, as both procedures lead to improvements in functional outcomes. [Orthopedics. 2018; 41(4):e457-e469.].

Technical pearls and surgical outcome of early transitional period experience in minimally invasive lumbar discectomy: A prospective study

Background:

There is growing indications of minimally invasive spine surgery. The inherent attitude and institutive learning curve limit transition from standard open surgery to minimally invasive surgery demanding understanding of new instruments and correlative anatomy.

Materials and Methods:

In this prospective study, 80 patients operated for lumbar disc prolapse were included in the study (between January 2016 and March 2018). Fifty patients (Group A) operated by various minimally invasive spine surgery (MISS) techniques for herniated disc disease were compared with randomly selected 30 patients (Group B) operated between the same time interval by standard open approach. Surgical outcome with Oswestry Disability Index (ODI) and patient satisfaction score was calculated in pre- and postoperative periods.

Results:

Mean preoperative ODI score in Group A was 31.52 ± 7.5 standard deviation (SD) (range: 6“46; interquartile range [IQR]: 8; median: 32.11) and postoperative ODI score was 9.20 ± 87.8 SD (range: 0“38; IQR: 11; median: 6.67). Mean preoperative ODI score in Group B was 26.47 ± 4.9 SD (range: 18“38; IQR: 4; median: 25) and postoperative ODI score was 12.27 ± 8.4 SD (range: 3“34; IQR: 12; median: 10.0). None of the patients was unsatisfied in either group. On comparing the patient satisfaction score among two groups, no significant difference (P = 0.27) was found.

Discussion:

On comparing the change in ODI and preoperative ODI among both groups, we found a significant difference between the groups. It is worth shifting from open to MISS accepting small learning curve. The satisfaction score of MISS in early transition period is similar to open procedure.

Conclusion:

The MISS is safe and effective procedure even in transition period for the central and paracentral prolapsed lumbar intervertebral disc treatment. The results are comparable, and patient satisfaction and symptomatic relief are not compromised.

Transforaminal Percutaneous Endoscopic Discectomy using Transforaminal Endoscopic Spine System technique: Pitfalls that a beginner should avoid

Transforaminal Percutaneous Endoscopic Discectomy (TPED) is a minimally invasive technique mainly used for the treatment of lumbar disc herniation from a lateral approach. Performed under local anesthesia, TPED has been proven to be a safe and effective technique which has been also associated with shorter rehabilitation period, reduced blood loss, trauma, and scar tissue compared to conventional procedures. However, the procedure should be performed by a spine surgeon experienced in the specific technique and capable of recognizing or avoiding various challenging conditions. In this review, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

The debate on most ideal technique for managing recurrent lumbar disc herniation: a short review

BACKGROUND

Though different techniques have been successfully employed in the treatment of recurrent lumbar disc herniation, the one which should be considered most ideal has remained a controversy, particularly since there are currently no generally accepted guidelines for surgical care.

OBJECTIVE

To review previous publications comparing the available operative options, with the aim of determining if any of the available interventions gives better outcomes compared to others.

METHODS

A systematic literature review of previous publications comparing various techniques employed in the surgical treatment of recurrent disc herniation.

RESULTS

All publications investigated in this review clearly demonstrated quite comparable outcomes, with no superiority of one method over the other.

CONCLUSION

In view of the currently available data and evidence, minimally invasive techniques for revision of recurrent disc herniation do not really appear to be superior to the conventional open surgical approaches and vice-versa. We suggest the management strategy for surgical treatment of each case of recurrence to be simply based on the experience of the surgeon, the available facilities and equipment. Fusion should not be undertaken in all recurrences but should only be considered as an option for revision when spinal instability, spinal deformity or associated radiculopathy is present.

Structural Preservation Percutaneous Endoscopic Lumbar Interlaminar Discectomy for L5-S1 Herniated Nucleus Pulposus

Objective. Structures such as ligamentum flavum, annulus, and lamina play an important role in the segmental function. We proposed the surgical technique for achieving the sufficient preservation of segmental structures, in spite of sufficient removal of pathologic disc in the L5-S1 using the ligamentum flavum splitting and sealing technique. Methods. We retrospectively analyzed 80 cases that underwent percutaneous endoscopic lumbar discectomy for L5-S1 herniated nucleus pulposus, using the ligamentum flavum splitting and sealing technique between January 2011 and June 2013. Outcomes were assessed using VAS (leg, back), MacNab's criteria, and the immediate postoperative MRI for all patients. Structural preservation was classified as complete, sufficient, and incomplete. Results. The surgical results are as follows: 65 cases were complete, 15 cases were sufficient, and 0 cases were incomplete. The VAS was decreased at the last follow-up (leg: from 7.91 ± 0.73 to 1.15 ± 0.62; back: from 5.15 ± 0.71 to 1.19 ± 0.75). A favorable outcome (excellent or good outcome by MacNab's criteria) was achieved in 77 patients (96.25%). During the follow-up period, 2 cases (2.5%) of recurrence have occurred. Conclusion. According to the result, we could obtain the favorable clinical and radiological outcomes while simultaneously removing pathologic discs using the ligamentum flavum splitting and annular fissure sealing technique.

Biportal Endoscopic Spinal Surgery for Recurrent Lumbar Disc Herniations

The major problems of revision surgery for recurrent lumbar disc herniation (LDH) include limited visualization due to adhesion of scar tissue, restricted handling of neural structures in insufficient visual field, and consequent higher risk of a dura tear and nerve root injury. Therefore, clear differentiation of neural structures from scar tissue and adhesiolysis performed while preserving stability of the remnant facet joint would lower the risk of complications and unnecessary fusion surgery. Biportal endoscopic spine surgery has several merits including sufficient magnification with panoramic view under very high illumination and free handling of instruments normally impossible in open spine surgery. It is supposed to be a highly recommendable alternative technique that is safer and less destructive than the other surgical options for recurrent LDH.

Treatment of Recurrent Disc Herniation: A Systematic Review

Intervertebral disc herniation is one of the most common causes of back and extremity pain. The most commonly used surgical treatment is lumbar discectomy. About 0.5-25% go on to develop recurrent disc herniation (rDH) after a successful first discectomy. Currently, there aren't any guidelines to assist surgeons in determining which approach is most appropriate to treat rDH. A recent survey showed significant heterogeneity among surgeons regarding treatment options for rDH. It remains unclear which methods lead to better outcomes, as there are no comparative studies with a sufficient level of evidence. In this study, we aimed to perform a systematic review to compare treatment options for rDH and determine if one intervention provides better outcomes than the other; more specifically, whether outcome differences exist between discectomy alone and discectomy with fusion. We applied the PICOS (participants, intervention, comparison, outcome, study design) format to develop this systematic review through PubMed. Twenty-seven papers from 1978-2014 met our inclusion criteria and were included in the analysis. Nine papers reported outcomes after discectomy and seven of them showed good or excellent outcomes (70.60%-89%). Ten papers reported on minimally invasive discectomy. The percent change in visual analog scale (VAS) ranged from -50.77% to -86.57%, indicating an overall pain reduction. Four studies out of the ten reported good or excellent outcomes (81% to 90.2%). Three studies looked at posterolateral fusion. Three studies analyzed posterior lumbar interbody fusion. For one study, we found the VAS percentage change to be -46.02%. All reported good to excellent outcomes. Six studies evaluated the transforaminal lumbar interbody fusion. All reported improvement in pain. Four used VAS, and we found the percent change to be -54% to -86.5%. The other two used the Japanese Orthopedic Association (JOA) score, and we found the percent change to be 68.3% to 93.3%. We did not find enough evidence to support any significant difference in outcomes between discectomy alone and discectomy with fusion. The limitation of our study includes the lack of standardized outcomes reporting in the literature. However, reviewing the selected articles shows that fusion may have a greater improvement in pain compared to reoperation without fusion. Nonetheless, our study shows that further and more in-depth investigation is needed on the of treatment of rDH.

State of the art: Transforaminal approach for percutaneous endoscopic lumbar discectomy under local anesthesia

Minimally invasive percutaneous endoscopic discectomy (PED) with a transforaminal approach under local anesthesia was started in the late 20th century. As the procedure requires a skin incision of only 8 mm, it is the least invasive disc surgery procedure at present, and owing to advances in instruments and optics, the use of this technique has gradually spread. In Japan, Dr. Dezawa from Teikyo University Mizonokuchi Hospital introduced this technique in 2003. Thanks to his efforts, the number of surgeons who can perform PED has increased, although the number of active PED surgeons is still only around 20. The first author (K.S.) started PED in 2010. In this review article, we explain the state-of-the-art PED transforaminal technique for minimally invasive disc surgery and present three successful cases.

Revision Surgery for "Real" Recurrent Lumbar Disk Herniation: A Systematic Review

STUDY DESIGN

A systematic review.

OBJECTIVE

To systematically review the previous literature regarding revision surgery for real recurrent lumbar disk herniation.

SUMMARY OF BACKGROUND DATA

"Real" recurrent lumbar disk herniation means the presence of herniated disk material at the same level and side as the primary disk herniation. If conservative treatment fails, revision surgery, a major concern, is indicated. It is important for both patients and spine surgeons to understand epidemiology trends and outcomes of revision surgery for real recurrent lumbar disk herniation (real-RLDH).

METHODS

The electronic databases PubMed, the Cochrane library, and EMBASE were queried for English articles regarding revision surgery for real-RLDH, published between January 1980 and May 2014. The incidence, interval between primary and revision surgery, risk factors, surgery type, complications, and clinical outcomes of revision surgery for real-RLDH were summarized.

RESULTS

The reported incidence of revision surgery, specifically for real-RLDH, lies between 1.4% and 11.4%. The complication rate is reported between 0% and 34.6%, with dural tear being the most common complication. Previous studies revealed that satisfactory or successful clinical outcome was achieved in 60%-100% of patients after revision surgery for real-RLDH. Several studies reported similar clinical outcomes between primary and revision surgery.

CONCLUSIONS

The incidence of revision surgery for real-RLDH is relatively low. It is essential to pay careful attention to prevent a dural tear. Patients may expect clinical outcomes similar to those following primary discectomy.

Endoscopic interlaminar approach for intracanal L5-S1 disc herniation: Classification of disc prolapse in relation to learning curve and surgical outcome

INTRODUCTION

The full endoscopic interlaminar approach (FEILA) is a minimally invasive procedure to treat intracanal lumbar disc herniation not approachable by endoscopic transforaminal access. Disc prolapses have been classified into three categories according to their position and passing nerve root displacement: (i) type A, in which the nerve root is displaced medially; (ii) type B, in which the nerve root is displaced laterally; and (iii) type C, in which the nerve root is ventrally displaced. We focused on the FEILA technique because it was likely to involve few complications and that provided the advantages of the endoscopic approach.

METHODS

We prospectively evaluated 100 consecutive cases of L5-S1 disc herniations operated on with FEILA, including 85 type A cases, 13 type B, and 2 type C. Patients were evaluated at discharge, 3 months, 6 months and 2 years.

RESULTS

The operating time varied from 15 to 40 min. The use of drills and burrs was necessary to treat type B disc herniations; thus, it was preferable that these cases were operated on later in the learning curve. After surgery, 90% of neurological deficits improved. The Oswestry Disability Index and visual analog scale leg at last follow-up were 15 and 9, respectively. There were no major complications. There were five cases of recurrence; four of which were treated with same technique and with good results.

CONCLUSION

FEILA is a safe procedure for the removal of intracanal L5-S1 disc herniations. The late follow-up confirms the stability of the results. We suggest treating type A prolapse at the beginning of the learning curve and type B herniations after sufficient experience in the use of the burrs has been achieved.

The surgical outcome and the surgical strategy of percutaneous endoscopic discectomy for recurrent disk herniation

STUDY DESIGN

A retrospective analysis.

OBJECTIVE

To present the surgical outcome of percutaneous endoscopic discectomy (PED) for recurrent herniated intervertebral disk disease (HIVD) and to suggest a surgical strategy.

SUMMARY OF BACKGROUND DATA

Revision discectomy is technically demanding because of the scar tissue, unclear anatomic planes, and retraumatization to the posterior structures. Although open microdiscectomy is a standard method, endoscopic techniques have emerged as a surgical alternative with comparable results. PED was performed with either the transforaminal (PETD) or the interlaminar approach (PEID). Previous reports have shown the surgical outcomes of PETD or PEID for recurrent HIVD, but the application of each approach was not addressed clearly.

METHODS

Consecutive 26 patients (M:F=16:10, mean age 53.1±12.4 y), who underwent PED for recurrent HIVD, were enrolled. The previous operation was an open discectomy in 22, a PETD in 2, and a PEID in 2 patients. PETD was considered preferentially, if it was feasible (n=11), because of the scar tissue formed by the previous operation. PEID was chosen (n=15) because of a high iliac crest (8), high canal compromise (3), high-grade inferior migration (2), and narrow neural foramen (2). All patients were followed up for 19.3±11.3 months.

RESULTS

In all patients, the recurrent disk material was removed successfully, and conversion to an open surgery was not necessary. Postoperative magnetic resonance imaging revealed that the ruptured disk was removed successfully in all cases. A favorable outcome (excellent or good outcome by MacNab's criteria) was achieved in 21 patients (81%). Re-recurrence occurred in 2 patients at 6 and 12 months postoperatively. Risk factors for an unfavorable outcome were not found in the present study (P>0.05).

CONCLUSIONS

The relevant utilization of updated surgical techniques may be helpful in overcoming the difficulty of revision surgery.

Comparison of two methods of epidural steroid injection in the treatment of recurrent lumbar disc herniation

Study Design

Prospective study.

Purpose

We compared the effects of two methods of epidural steroid injection in patients with recurrent disc herniation.

Overview of Literature

To our knowledge, there is no previous report of such a comparison in these patients.

Methods

The study was performed with 30 patients with relapsed lumbar disc herniation whose pain was not relieved by conservative remedies. The patients were divided into two groups, each of 15 patients, and entered the study for caudal or transforaminal injections. The degree of pain, ability to stand and walk, and the Prolo function score were evaluated in both groups before the injection and 2 months and 6 months after the injection.

Results

The degrees of pain reduction in the caudal injection group in the second and sixth months were 0.6 and 1.63, respectively, and in the transforaminal injection group were 1.33 and 1.56, respectively. The difference between the two methods was not statistically significant. Similarly, no other evaluated criterion showed a significant difference between the methods.

Conclusions

In the current study, the caudal and transforaminal steroid injection methods showed similar outcomes in the treatment of relapsed lumbar disc herniation. However, more detailed patient categorizing may help in finding possible subgroups with differences.