A Comparison of Minimally Invasive Surgical Techniques and Standard Open Discectomy for Lumbar Disc Herniation: A Network Meta-analysis

BACKGROUND

Lumbar disc herniation is a common spinal disease that causes low back pain; surgery is required when conservative treatment is ineffective. There is a growing demand for minimally invasive surgery in younger patient populations due to their fear of significant damage and a long recovery period following standard open discectomy. The development history of minimally invasive surgery is relatively short, and no gold standard has been established.

OBJECTIVES

We aimed to find, via a network meta-analysis, the best treatment for low back pain in younger patient populations.

STUDY DESIGN

Network meta-analysis.

METHODS

The PubMed, Embase, Cochrane Library, and Web of Science databases were searched. Data quality was evaluated using RevMan 5.3 (The Nordic Cochrane Centre for The Cochrane Collaboration), while STATA 14.0 (StataCorp LLC) was used for the network meta-analysis and to merge data on the Visual Analog Scale (VAS) score, Oswestry Disability Index (ODI) score, complication, blood loss, reoperation rate, and function score.

RESULTS

We included 50 randomized controlled trials, involving 7 interventions; heterogeneity and inconsistency were acceptable. Comparatively, microendoscopic discectomy and percutaneous endoscopic lumbar discectomy were the best surgical procedures from the aspects of VAS score and ODI score, while standard open discectomy was the worst one from the aspect of ODI score. Regarding complications, tubular discectomy was preferred with the fewest complications. Additionally, microendoscopic discectomy outperformed other surgical procedures in reducing blood loss and reoperation rate.

LIMITATIONS

First, follow-up data were not reported in all included studies, and the follow-up time varied from several months to 8 years, which affected the results accuracy of our study to some extent. Second, there were some nonsurgical factors that also affected the self-reported outcomes, such as rehabilitation and pain management, which also brought a certain bias in our study results.

CONCLUSIONS

Compared to standard open discectomy, minimally invasive surgical procedures not only achieve satisfactory efficacy, but also microendoscopic discectomy and percutaneous endoscopic lumbar discectomy can obtain a more satisfactory short-term VAS score and ODI score. Microendoscopic discectomy has significant advantages in blood loss and reoperation rate, and tubular discectomy has fewer postoperative complications.

Endoscopic Versus Microscopic Microvascular Decompression for Trigeminal Neuralgia: A Prospective Controlled Study

BACKGROUND

Several studies have suggested favorable results with endoscope-assisted microvascular decompression (EA-MVD) for treating patients with trigeminal neuralgia (TN); however, supporting evidence is limited.

OBJECTIVES

This study aimed to compare the efficacy and safety of EA-MVD with microscopic microvascular decompression (M-MVD).

STUDY DESIGN

Prospective controlled study.

SETTING

We performed a prospective controlled clinical study that included 52 patients with TN (36, [69.2%] women; 16, [30.8%] men), from June 2021 through January 2022.

METHODS

Patients were assigned to receive either EA-MVD (n = 23) or M-MVD (n = 29). The primary outcome was pain intensity relief, measured using the Visual Analog Scale (VAS) and the Barrow Neurological Institute grading scale. The secondary outcomes were the detection of multiple offending vessels, endoscopic use, operation time, hospital stay length, and complications. All patients were followed-up for >= 12 months.

RESULTS

At 12 months, both treatment groups showed similar improvements in pain intensity (P = 0.099). The mean VAS score was 3.5 ± 1.6 and 2.9 ± 1.7 in the EA-MVD and M-MVD groups, respectively. Overall, most patients in both groups reached a pain-free status or had nearly pain-free relief (EA-MVD: 21/23, 91.3%; M-MVD: 27/29, 93.1%). The incidence of multiple offending vessels was higher in the EA-MVD group than in the M-MVD group (52.2% vs 17.2%, P = 0.038). The mean operating time in the EA-MVD group (158 ± 27 minutes) was longer and the hospital stay (6 ± 1 days) was shorter than those of the M-MVD group (144 ± 25 minutes and 8 ± 4 days). No mortality or endoscope-related serious adverse events were noted, with the exception of an intracranial infection case in the M-MVD group.

LIMITATIONS

The mean follow-up time was relatively short and a single-center study and a small patient population, which might bring some clinical bias.

CONCLUSIONS

M-MVD and EA-MVD achieved similar analgesic effects for TN; however, EA-MVD allowed observation of more probable offending vessels with good flexible operative visualization.

Shape Memory Nitinol Based Minimally Invasive Spinal Cord Stimulation Device Concept for Improved Pain Management

BACKGROUND

Spinal cord stimulation (SCS) is a common treatment for neuropathic pain. There are 2 main categories of SCS leads: paddle leads and cylindrical leads. Paddle leads have reduced long-term complications and provide better coverage of target dermatomes when compared to cylindrical leads. However, insertion of a paddle lead requires invasive surgery that comes with significantly higher costs and more short-term complications, such as postoperative pain and infection. In contrast, cylindrical leads can be inserted minimally invasively using percutaneous techniques but provide less coverage of targeted dermatomes and have a higher tendency to migrate from intended neuronal targets.

OBJECTIVES

Our objective is to develop a novel improved cylindrical spinal cord stimulation device that can convert into an optimal geometry once exposed to the body's environment after minimally invasive surgery. Such a device would be able to reduce long-term complications, lead migration, and better cover targeted dermatomes.

STUDY DESIGN

Biomaterial selection, medical intervention device design with an in-vitro lab-scale test, and cadaveric experimental study.

METHODS

A shape memory alloy nitinol-based cylindrical lead was designed, and its nitinol core material was processed and geometrically programmed for percutaneous insertion into the epidural space and morphing into an optimal geometry once exposed to the body's environment. Deployment of the nitinol component of the design was tested in the lab and human cadaveric models of the epidural space.

RESULTS

Deployment of the nitinol component of the proposed cylindrical lead was successfully demonstrated in both a lab model of the epidural space and in the epidural space of a human cadaver in a minimally invasive fashion, indicating that a similar component could be used clinically in a full SCS electrode manufactured in a custom final geometry.

LIMITATIONS

The focus of this study was to test the deployment of a novel minimally invasive lead that provides optimal coverage of intended dermatomes using in-vitro methods. Our study does not include in vivo trials. We do not test the electrical components of the design proposed since our design does not make changes to the electrical components of current commercially used cylindrical leads.

CONCLUSION

The unique shape memory property of nitinol shows promise in allowing cylindrical spinal cord stimulation leads to expand into a more optimal geometry within the epidural space. By having a body temperature-dependent geometry change, nitinol-based cylindrical leads could reduce lead migration, increase dermatomal coverage, and increase electrode density while maintaining the advantages of minimally invasive insertion.

Bi-Needle PELD with Intra-Discal Irrigation Technique for the Management of Lumbar Disc Herniation

BACKGROUND

Lumbar disc herniation (LDH) is the most common cause of sciatica. Percutaneous endoscopic discectomy (PELD) is indicated when conservative treatments fail, which has been proved effective. During conventional PELD, ruptured discs and loose fragments inside discs are removed as much as possible to guarantee a lower reherniation rate, but it inevitably would lead to deterioration of disc degeneration and loss of disc height after PELD. Ensuring sufficient decompression while alleviating the post-operation disc degeneration process is still a clinical problem.

OBJECTIVE

To evaluate the imaging and clinical outcomes of bi-needle PELD with intradiscal irrigation technique for the treatment of lumbar disc herniation (LDH).

STUDY DESIGN

Multicenter retrospective cohort study.

SETTING

Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China.

METHODS

A total of 48 patients who underwent bi-needle PELD (B-PELD) or conventional-PELD (C-PELD) for LDH in our 2 spine centers were included in this study. There were 26 cases in the C-PELD group (male 12 cases, female 14 cases) with an average age of 34.6 ± 6.8 years. And there were 22 patients in the B-PELD group (male 10 cases, female 12 cases) with an average age of 35.1 ± 6.4 years. The difference in postoperative disc degeneration (Pfirrmann grades, disc-vertebra height ratios [D-V H ratios]), visual analog scale (VAS) of low back pain, and reoperation rates were compared between the 2 groups.

RESULTS

There was no significant difference in gender, age, disease duration, and surgical level between the 2 groups (P > 0.05). The postoperative VAS of back pain was 2.31 ± 0.53 for the C-PELD group and 0.63 ± 0.74 for the B-PELD group; the difference was significant (P = 0.013). The difference between the preoperative and postoperative D-V H ratios in the C-PELD group was significant (P < 0.0001), while it was not significant in the B-PELD group (P = 0.6708). The difference between the loss of D-V H ratios after surgery was significant between the 2 groups (P = 0.0003). The loss of D-V H ratios was higher in the C-PELD group. The difference between the preoperative and postoperative Pfirrmann grades in the B-PELD group was not significant (P = 0.7261); however, it was significant in the C-PELD group (P = 0.0012). The reoperation rate in the C-PELD group was 7.7%, and the reoperation rate in the B-PELD group was 4.5%; the difference was not significant (P = 1).

LIMITATIONS

This study employed a retrospective design, and its inherent selection bias and limited statistical power should be considered.

CONCLUSIONS

Bi-needle technique with saline irrigation maneuver showed a significant advantage of restoration of disc height and amelioration of disc degeneration compared to conventional PELD surgery.

Comparison of Different Operative Approaches for Lumbar Disc Herniation: A Network Meta-Analysis and Systematic Review

BACKGROUND

New approaches and technologies can be beneficial for patients but also bring corresponding complications. Traditional pairwise meta-analyses cannot be used to comprehensively rank all surgical approaches.

OBJECTIVES

The purpose of this systematic review and network meta-analysis (NMA) was to compare the outcomes of different surgical approaches for lumbar disc herniation (LDH).

STUDY DESIGN

NMA of randomized controlled trials (RCTs) for multiple treatment comparisons of LDH.

METHODS

The PubMed, Embase, MEDLINE, Ovid, and Cochrane Library databases were searched for RCTs comparing different surgical approaches for patients with LDH from inception to February 10, 2020. The Markov chain Monte Carlo methods were used to perform a hierarchical Bayesian NMA in WinBUGS version 1.4.3 using a random effects consistency model. The primary outcomes were disability and pain intensity. The secondary outcomes were complications and reoperation. The PROSPERO number was CRD42020179406.

RESULTS

A total of 22 trials including 2529 patients and all 5 different approaches (open discectomy or microdiscectomy [OD/MD], microendoscopic discectomy [MED], percutaneous endoscopic discectomy [PED], percutaneous discectomy [PD], and tubular discectomy [TD]) were retrospectively retrieved. PED had the best efficacy in improving patients' dysfunction with no statistical significance (probability = 50%). PD was significantly worse than OD/MD, MED, and PED in relieving patients' pain (standardized mean differences: 0.87 [0.03, 1.76], 0.94 [0.06, 1.88], and 1.02 [0.13, 1.94], respectively). There was no statistically significant difference between any 2 surgical approaches in dural tear; intraoperative, postoperative, and overall complications; or reoperation rate. PED had the lowest dural tear rate and the lowest intraoperative and overall complication rates (probability = 51%, 67%, and 33%, respectively). TD had the lowest postoperative complication and reoperation rates (probability = 35% and 39%, respectively).

LIMITATIONS

The limitations of this NMA include the inconsistent follow-up times, the criteria for complications, and the reasons for reoperation.

CONCLUSIONS

Compared with other approaches used to treat LDH, PED had the best safety and efficacy in general, and TD had the lowest reoperation rate. Finally, we recommended PED for LDH.

Ultrasonic Osteotome Assisted Full-Endoscopic en Block Resection of Thoracic Ossified Ligamentum Flavum: Technical Note and 2 Years Follow-up

BACKGROUND

Conventional open laminectomy is considered to be the standard procedure for the treatment of thoracic ossified ligamentum flavum, but multi-segment thoracic laminectomy extensively removes the facet joints and ligamentous tissue, destroying the thoracic spine biomechanics and stability, may lead to delayed thoracic spine kyphosis deformities, which in turn can lead to potential neurological deterioration and local intractable pain.

OBJECTIVE

To introduce the technical notes and clinical outcome of ultrasonic osteotome assisted full-endoscopic en block resection of thoracic ossified ligamentum flavum.

STUDY DESIGN

A prospective cohort study.

SETTING

Hospital and outpatient surgery center.

METHODS

From January 2017 to March 2018, 15 patients with 1 - 2 segment thoracic ossified ligamentum flavum were treated with ultrasonic osteotome assisted full-endoscopic en block resection of thoracic ossified ligamentum flavum under local anesthesia. The magnetic resonance imaging and computed tomography of the thoracic spine was reexamined after the operation to evaluate the completeness of ossified ligamentum flavum resection and spinal cord decompression. The patients were followed up on the visual analog scale of back pain and radicular pain, Nurick score and mJOA score of neurological function, and Oswestry Disability Index at 1 week, 3 months, 6 months, one year, and 2 years after operation.

RESULTS

All operations of 17 segments thoracic ossified ligamentum flavum in 15 patients were successfully completed without intraoperative conversion to open surgery. There were no intraoperative spinal cord injuries, dura tears, postoperative cerebrospinal fluid leakage, postoperative infections, and postoperative spinal cord injury aggravated symptoms. Postoperative thoracic spine magnetic resonance imaging and computed tomography examinations of all patients showed that the spinal cord was fully decompressed without any residual pressure. Back pain and radicular pain were relieved significantly, and spinal cord function (Nurick, mJOA, and Oswestry Disability Index scores) was obviously restored. The mJOA recovery rate at the 2-year follow-up was 78.3% in average.

LIMITATIONS

This is an observational cohort study with relative small sample and short-term follow-up.

CONCLUSIONS

Ultrasonic assisted full-endoscopic en block resection of ossified ligamentum flavum is a safe and effective minimally invasive spine surgery for thoracic myelography caused by thoracic ossified ligamentum flavum.

[Yishen Tongluo Recipe combined with minimally invasive surgery for the treatment of varicocele-associated asthenospermia]

OBJECTIVE

To observe the clinical effect of Yishen Tongluo Recipe (YTR) combined with minimally invasive surgery (MIS) in the treatment of varicocele-associated asthenospermia (of the kidney-deficiency and collateral-obstruction type).

METHODS

We randomly divided 116 patients with varicocele-associated asthenospermia and up to the inclusion criteria into three groups and treated them by YTR combined with MIS (low spermatic vein ligation at the external inguinal ring orifice under the microscope) (the YTR+MIS group, n = 39), YTR alone (the YTR group, n = 38), or MIS alone (the MIS group, n = 39). At 12 weeks after treatment, we compared the total effectiveness rate, the percentage of progressively motile sperm (PMS), sperm straight line velocity (VSL), sperm DNA fragmentation index (DFI) and symptoms among the three groups of patients.

RESULTS

After treatment, the total effectiveness rate was significantly higher in the YTR+MIS than in the YTR and the MIS group (89.74% vs 63.16% and 64.10%, P < 0.05), and so were the percentage of PMS (31.67 ± 3.93 vs 24.48 ± 3.15 and 25.57 ± 3.37, P < 0.05) and VSL (［30.19 ± 5.32］ vs ［27.19 ± 5.48］ and ［27.55 ± 5.24］ μm/s, P < 0.05), but the DFI was remarkably lower in the former than in the latter two groups (11.25 ± 8.27 vs 15.87 ± 5.45 and 15.26 ± 4.36, P < 0.05). The symptoms were improved more significantly in the YTR+MIS than in the YTR and MIS groups (P < 0.05).

CONCLUSIONS

Yishen Tongluo Recipe combined with minimally invasive surgery, as an effective and safe strategy, can significantly improve sperm quality and sperm DNA integrity in patients with varicocele-associated asthenospermia.