Microdiscectomy Research Articles

Transforaminal Endoscopic Discectomy versus Microdiscectomy for Treatment of Lumbar Disc Herniation and Associated Unilateral Sciatica: A Comparative Study

Abstract Background Data: Recently, transforaminal endoscopic discectomy (TED) has become accepted as a safe alternative procedure for microdiscectomy (MID) in lumbar disc surgery. Numerous studies compared microdiscectomy with interlaminar endoscopic discectomy; however, the number of studies comparing MID with TED is relatively limited. Purpose: To compare TED and MID in treating lower lumbar disc prolapse (LDP) and associated unilateral sciatica in terms of overall outcome, complications, and rate of recurrence. Study Design: Retrospective clinical case series. Patients and Methods: This retrospective study included one hundred patients with low back pain and unilateral sciatica due to lower lumbar herniated discs. They were divided into 2 groups, each one consisted of 50 patients: Group A underwent MID and Group B TED. Clinical assessments of all patients were conducted using Visual Analogue Score (VAS) and Oswestry Disability Index (ODI) preoperatively and at one-year postoperative follow-up. Results: In this study, one hundred patients were surgically treated (50 for MID and 50 for TED) from June 2017 to December 2018. The mean age was 40.44 ± 11.31 and 41.14 ± 11.60 years for MID and TED, respectively. Males were most affected in both TED and MID groups (76% in MID and 66% in TED). The most affected disc level in both groups was the L4-L5 level, representing 60% and 68% for MID and TED, respectively. The mean operative time was 63.82 ± 17.37 and 72.60 ± 16.90 minutes for MID and TED, respectively, with significant difference (p = 0.02). Upon comparing the postoperative values, all patients in both groups showed a significant improvement in their preoperative back pain, leg pain, and ODI scores. According to Macnab’s Outcome Criteria, in our study, the results were as follows: for the MED group, overall good to excellent outcomes in 92% (N = 46), fair in 4% (N = 2), and poor in 4% (N = 2); for the TED group, overall good to excellent outcomes in 86% (N = 43), fair in 6% (N = 3), and poor in 8% (N = 4). Conclusion: Percutaneous posterolateral transforaminal discectomy has become a relatively safe and effective procedure over the last years; however, MID is the gold standard surgical approach till now for treating LDP and associated sciatica. (2020ESJ211) Abstract Background Data: Recently transforaminal endoscopic discectomy become accepted as a safe alternative procedure for microdiscectomy in lumbar disc surgey. There are a lot of studies comparing the microdiscectomy with the interlaminar endoscopic discectomy ,but the number of studies which comparing the microdiscectomy with the transforaminal endoscopic one are relatively limited Purpose: In this study, we aim to compare between transforaminal endoscopic discectomy and microdiscectomy in treatment of lower lumbar disc prolapse and associated unilateral sciatica in terms of overall outcome, complications, and rate of recurrence. Study design: Retrospective clinical case series. Patients and methods A retrospective study involved one hundred (100) patients with low back pain and unilateral sciatica due to lower lumbar herniated discs divided into 2 groups each one consisted of 50 patients ,group (A) treated with microdiscectomy (MID),group(B) operated by transforaminal endoscopic discectomy(TED). Preoperative clinical assessment of all patients has done using visual analogue score (VAS) and Oswestry Disability Index (ODI) and follow up was done at 1 month,6month, and 12, months postoperatively. Results: In the current study, one hundred (100) patients were surgically treated (50 for MID and 50 for TED) from June 2017 to December 2018, the mean age (40.44± 11.31 &41.14 ±11.60 years for MID and TED respectively, males were most affected in both TED and MID groups (76% in MID and 66% in TED). The most affected disc level in both groups was L4-5 level(60%&68% for MID and TED respectively).Mean operative time was(63.82 ±17.37&72.60 ±16.90 minutes for MID and TED respectively with Significant difference P<0.05). The mean hospital stay was (29.80± 31.73&14.76± 11.20 hours for MID and TED respectively with significant relation P=0.02). Compared to the post-operative values, all patients in both groups showed a significant improvement of their preoperative back pain, leg pain and ODI scores. According to Mac Nab’s Outcome Criteria, in our study, overall good to excellent results for MED group (46pts, 92%), fair (2pts 4%) and poor outcome in (2 pts 4%).and overall good to excellent of TED group was (43 pts, 86%), fair (3pts, 6%), poor outcome (4pts, 8%). Conclusion: Percutaneous posterolateral transforaminal discectomy has become a relative safe, effective procedure over the last years, but microdiscectomy is the gold standard surgical approach till now for treatment of lumbar disc prolapse and associated sciatica. Key words: Transforaminal, microdiecectomy, endoscopic, sciatica, kambin, dysesthesia

Recurrence Rate of Lumbar Disc Herniation After Standard Discectomy and Microdiscectomy: A 5-Year Study

Summary Lumbar disc herniation (LDH) is the most common pathology in young people, as well as people of active age. Despite sophisticated and new minimally invasive surgical techniques and approaches, reoperations for recurrent lumbar disc herniation (rLDH) could not be avoided. LDH recurrence rates, reported in different studies, range from 5 to 25%. The purpose of this study was to estimate the recurrence rates of LDH after standard discectomy (SD) and microdiscectomy (MD), and compare them to those reported in the literature. Retrospectively, operative reports for the period 2012-2017 were reviewed on LDH surgeries performed at the Neurosurgery Clinic of Dr Georgi Stranski University Hospital in Pleven. Five hundred eighty-nine single-level lumbar discectomies were performed by one neurosurgeon. The diagnoses of recurrent disc herniation were based on the development of new symptoms and magnetic resonance/computed tomography (MRI/CT) images showing compatible lesions in the same lumbar level as the primary lumbar discectomies. The recurrence rate was determined by using chi-square tests and directional measures. SD was the most common procedure (498 patients) followed by MD (91 patients). The cumulative reoperation rate for rLDH was 7.5%. From a total number of reoperations, 26 were males (59.1%) and 18 were females (40.9%). Reoperation rates were 7.6% and 6.6% after SD and MD respectively. The recurrence rate was not significantly higher for SD. Our recurrence rate was 7.5%, which makes it comparable with the rates of 5-25% reported in the literature.

Cost-effectiveness of microdiscectomy versus endoscopic discectomy for lumbar disc herniation

Microdiscectomy is a standard technique for the surgical treatment of lumbar disc herniation (LDH). Endoscopic discectomy (ED) is another surgical option that has become popular owing to reports of shorter hospitalization and earlier return to work. No study has evaluated health care costs associated with lumbar discectomy techniques and compared cost-effectiveness. To assess the cost-effectiveness of four surgical techniques for LDH: microdiscectomy (MD), transforaminal endoscopic lumbar discectomy (TELD), interlaminar endoscopic lumbar discectomy (IELD), and unilateral biportal endoscopic discectomy (UBED). Retrospective analysis. Patients who underwent either MD or ED for primary LDH with 1-year follow-up between the ages of 20 and 60 years old. Incremental cost-effectiveness ratio (ICER). Five hundred sixty-five patients aged 20-60 years who underwent treatment using one of the four surgical techniques with at least 1-year follow-up were reviewed. Health care costs were defined as the sum of direct and indirect costs. The former included the covered and uncovered costs of the National Health Insurance from operation to 1-year follow-up; indirect costs included costs incurred by work loss. Direct and indirect costs were evaluated separately. ICER was determined using cost/quality-adjusted life year (QALY). Health care costs and ICER were compared statistically among the four surgical groups. Cost-effectiveness was compared statistically between MD and ED. One hundred fifty-seven patients who underwent TELD, 132 for IELD, 140 for UBED, and 136 for MD were enrolled. The direct costs of TELD, IELD, UBED, and MD were $3,452.2±1,211.5, $3,907.3±895.3, $4,049.2±1,134.6, and $4,302.1±1,028.9, respectively (p<.01). The indirect costs of TELD, IELD, UBED, and MD were $574.5±495.9, $587.8±488.3, $647.4±455.6, and $759.7±491.7, respectively (p<.01). The 1-year QALY gains were 0.208 for TELD, 0.211 for IELD, 0.194 for UBED, and 0.186 for MD. ICER (costs/QALY) was the highest for MD ($34,840.4±25,477.9, p<.01). Compared with MD, ED saved an additional net of $8,064 per QALY (p<.01). There was no significant difference in the ICERs among the three endoscopic techniques. ED was more cost-effective compared with MD at 1-year follow up.

Open Discectomy vs. Microdiscectomy: Results from 519 Patients Operated for Lumbar Disc Herniation.

The aim of this study was to evaluate the outcomes of patients with lumbar disk hernia operated between 2012 January and 2017 August and to compare the differences between open discectomy (OD) and microdiscectomy (MD). Files of 519 patients who presented at our neurosurgical department with lumbar disk herniation were retrospectively reviewed and recorded. Preoperatively, all patients routinely underwent spinal lumbar magnetic resonance imaging (MRI) and anteroposterior as well as lateral lumbar vertebrae X-rays. During the early postoperative period, there was no need for imaging. Surgical interventions were performed using the two currently accepted OD and MD methods. We reviewed 519 patients with lumbar disk herniation who were operated in our clinic between 2012 and 2017. The mean age of 276 patients who underwent OD was 44.85±9.92 y, and that of the remaining 243 patients who underwent MD was 47.69±12.87 y. There was no difference in the demographic distributions of patients; levels of lumbar disk herniations; postoperative clinical outcomes; and long-term reoperation rates due to root injury, wound infection, dural tear, or the recurrence of lumbar disk herniation (p>0.05). The duration of operation was significantly shorter for OD (37.82±7.15 vs. 49.07±6.88 min; t=-18.184, p<0.001). The long-term results of patients who underwent OD and MD for lumbar disk herniation were similar. We believe that both methods can be safely used under appropriate conditions and surgical experience and that surgical experience has an impact on their outcomes.

Comparison of Surgical Invasiveness Between Microdiscectomy and 3 Different Endoscopic Discectomy Techniques for Lumbar Disc Herniation

Muscle injury is inevitable during surgical exposure of the spine. This study compared paraspinal muscle injury after 4 surgical techniques: microdiscectomy (MD), percutaneous endoscopic lumbar discectomy (PELD), percutaneous endoscopic interlaminar discectomy (PEID), unilateral biportal endoscopic discectomy (UBED). Eighty patients who underwent MD, PELD, PEID, and UBED were prospectively observed. Creatine phosphokinase (CPK) and C-reactive protein levels were measured on admission and postoperative days 1, 3, 5, and 7. CPK ratio was calculated as CPK on postoperative day 1/CPK on admission. Cross-sectional area of the high-intensity lesion in the paraspinal muscle was measured on magnetic resonance imaging after surgery. Operative time and hospital stay duration were also examined. Clinical outcome was evaluated using the visual analog scale for back and leg pain. MD group had the highest CPK levels on postoperative days 1 and 3 and CPK ratio (P < 0.01, P= 0.02, P=0.04). Serial C-reactive protein levels were highest in MD group (P < 0.01). PELD and PEID groups had lower C-reactive protein level on postoperative day 1 than UBED group. MD group had largest cross-sectional area (P < 0.01). Cross-sectional area was larger in UBED group than in PELD and PEID groups (P < 0.01). Operative time and hospital stay duration were shortest in PELD group (P < 0.01, P < 0.01). MD group had significantly higher visual analog scale scores for back pain on postoperative days 1 and 3 than the other groups (P < 0.01, P= 0.02). PELD is the least invasive spinal surgical technique.

OUTCOMES OF TRANSFORAMINAL ENDOSCOPIC DISCECTOMY FOR LUMBOSACRAL DISC HERNIATION

Introduction. Lumbar disc herniation is a frequent pathology and surgical target. Endoscopic discectomy becomes more popular due to minimally invasive surgical technique. There is a deficit of scientific papers dedicated to analysis of potential for endoscopic discectomy depending on the specifics of spinal anatomy and degenerative changes.The purpose of the study was to evaluate the efficacy of transforaminal endoscopic discectomy (TED) in comparison with microdiscectomy (MD) and to specify factors determining complications and failures.Materials and methods. The authors performed randomized controlled study where main group of patients included data on prospective examination of 101 patients after TED procedure for lumbar intervertebral disc herniation. Age of patients ranged from 19 to 81 years with average of 41,4±12,6 years. Control group included data of retrospective examination of 153 patients that were operated by the same surgeon in the period from 201 till 2104 with microdiscectomy procedure. Age of patients ranged from 18 to 77 years with average of 47,8±11,3 years. Inclusion criteria were as follows: surgical procedure at the same level of the primary intervertebral herniation. Exclusion criteria were: degenerative spinal canal stenosis, spondylolisthesis, spine deformity.Results. Clinical outcomes after TED demonstrated no difference from MD procedure. No factors of significant influence on outcomes after surgical procedure were observed. The main group was characterized by more cases of revisions and conversions of endoscopic into open procedures (13,9%) which was related to mistakes in transforaminal approach due to features of intervertebral joints and foramina anatomy resulting in impossibility to achieve adequate spinal canal decompression.Conclusion. Transforaminal endoscopic discectomy is an effective and safe method of lumbar intervertebral herniation treatment. Complications and failures during learning curve of endoscopic procedure are associated with technique drawbacks as well as with mistakes in planning and performing the approach. Congenital alignment of lumbar spine with specific patterns of facets and foramina anatomy dictate technical difficulties with transforaminal approach.

P202 - Operative Approaches for Lumbar Disc Herniation: A Systematic Review and Multiple Treatment Meta-Analysis of Conventional and Minimally Invasive Surgeries

BACKGROUND CONTEXT: Since the late 1920s, many surgical procedures have been defined to operate on lumbar disc herniation, the Gold-Standard among them being open discectomy (OD) and microdiscectomy (MD). In the last two decades, many minimally invasive procedures have been introduced and implemented into practice. Such approaches include percutaneous (PD), percutaneous endoscopic (PED) and tubular discectomy (TD).

Cerebral Oxygenation Changes Observed in Patients Undergoing Spinal Neurosurgery in Prone Position Using Near Infrared Spectroscopy

Background: Near infrared spectroscopy (NIRS) devices like cerebral oximeters have lately gained their actuality in different medical fields. Used intraoperative they can early detect harmful event and gives a possibility to avoid from further brain damage. The goal of the study was to determine whether prone position during spinal neurosurgery impacts cerebral oxygen saturation using NIRS. Material and methods: 28 patients (mean age 56±12.5y) underwent spinal neurosurgery in prone position (transpedicular fixation (TPF) = 15, micro discectomy (MDE) = 8, spinal tumor removal (spinal Tu) = 5). Cerebral oxygen saturation (rScO2) was continuously monitored using INVOS 4100 cerebral oximeter. We also assessed blood loss, postoperative complications (stroke, organ dysfunction, wound infection, days spent in ICU) and cognitive dysfunction using MoCA Montreal - Cognitive Assessment scale. All patients received standard general anaesthesia. All patients were extubated in the operating room. Results: Significant changes in calculated mean rScO2 values between supine and prone position during the surgery were not observed. Mean rScO2 during the whole surgery was 73% above the right cerebral hemisphere (R), 73% above the left (L). Lying supine during induction R72%, L71%, in prone position R74%, L74%, returning back to spinal position R73%, L73%. 11 out of 28 patients showed a slight to significant decrease in rScO2 values in prone position. One patient showed a rScO2 decrease by 27% from baseline value. Average blood loss was 308ml. Average duration of operation was 110min. No incidence of stroke, organ dysfunction was observed. One patient was admitted to ICU due to blood loss. One patient showed cognitive dysfunction.

Standard Lumbar Discectomy Versus Microdiscectomy - Differences in Clinical Outcome and Reoperation Rate.

Microdiscectomy (MD) is accepted nowadays as the operative method of choice for lumbar disc herniation, but it is not rare for neurosurgeons to opt for standard discectomy (SD), which does not entail the use of operating microscope. In our study, differences in disc herniation recurrence and clinical outcome of surgical treatment of lumbar disc herniation with and without the use of operating microscope were assessed. Our study included 167 patients undergoing lumbar disc surgery during a three-year period (SD, n=111 and MD, n=56). Clinical outcome assessments were recorded by patients via questionnaire forms filled out by patients at three time points. Operation duration, length of hospital stay and revision surgeries were also recorded. According to study results, after one-year follow up there was no statistically significant difference between the SD and MD groups in functional outcome. However, we recorded a statistically significant difference in leg pain reduction in favor of the MD group. According to the frequency of reoperations with the mean follow up period of 33.4 months, there was a statistically significant difference in favor of the MD group (SD 6.3% vs. MD 3.2%). There appears to be no particular advantage of either technique in terms of functional outcome since both result in good overall outcome. However, we choose MD over SD because it includes significantly lower recurrent disc herniation rate and higher reduction of leg pain.

Full-Endoscopic Interlaminar Versus Microsurgical Operations in Lumbar Compressive Lesions Surgery: Prospective Randomized Trial of Overall 570 Patients

Introduction: Full-endoscopic operations of lumbar spine are truly minimally invasive surgical procedures and they have become the standard because of their intraoperative and postoperative advantages.Aim: To compare clinical outcomes of full-endoscopic interlaminar technique to conventional microdiscectomy performed during 3 year period.Materials and Methods: A series of 350 patients underwent full-endoscopic interlaminar lumbar discectomy, comparing 220 patients with microdiscectomy and spinal canal decompression, during a 3-year period, is analysed. Oswestry Disability Index (ODI), visual analogue scores (VAS) of back and leg pain were measured preoperatively and at 1, 6, 12, 24 months.Results: All outcome measures improved significantly in both groups (p<0.001). In the full-endoscopic group 88% of the patients no longer had leg pain, and 7% had only occasional pain, postoperatively. In the microdiscectomy (MI) group 78.1% had significant improvement, 13.6% had improvement with occasional pain, and 8% had no improvement. The recurrence rate was 8%. Resection of the herniated disc and sufficient decompression was technically possible in all cases. The overall complication rate (16.4%), and recurrence-reoperation rate (11.8%) was significantly higher in the MI group.Conclusion: The clinical results of the full-endoscopic technique are at least equal to those of the conventional microsurgical discectomy with advantages such as reduced traumatization, improved patient mobility, and lower complication and recurrence rate. With the possibility of selecting the most adequate approach, lumbar disc herniations inside and outside the spinal canal, can be sufficiently removed using the full-endoscopic technique, when taking the appropriate indication criteria into account.

Open discectomy vs microdiscectomy for lumbar disc herniation - a protocol for a pragmatic comparative effectiveness study

Introduction: Since the introduction of lumbar microdiscectomy in the 1970’s, many studies have attempted to compare the effectiveness of this method with that of standard open discectomy with conflicting results. This observational study is designed to compare the relative effectiveness of microdiscectomy (MD) with open discectomy (OD) for treating lumbar disc herniation, -within a large cohort, recruited from daily clinical practice. Methods and analysis: This study will include patients registered in the Norwegian Registry for Spine Surgery (NORspine). This clinical registry collects prospective data, including preoperative and postoperative outcome measures as well as individual and demographic parameters. The primary outcome is change in Oswestry disability index between baseline and 12 months after surgery. Secondary outcome measures are improvement of leg pain and changes in health related quality of life measured by the Euro-Qol-5D between baseline and 12 months after surgery, complications to surgery, duration of surgical procedures and length of hospital stay.

Open discectomy vs microdiscectomy for lumbar disc herniation - a protocol for a pragmatic comparative effectiveness study.

Introduction: Since the introduction of lumbar microdiscectomy in the 1970's, many studies have attempted to compare the effectiveness of this method with that of standard open discectomy with conflicting results. This observational study is designed to compare the relative effectiveness of microdiscectomy (MD) with open discectomy (OD) for treating lumbar disc herniation, -within a large cohort, recruited from daily clinical practice. Methods and analysis: This study will include patients registered in the Norwegian Registry for Spine Surgery (NORspine). This clinical registry collects prospective data, including preoperative and postoperative outcome measures as well as individual and demographic parameters. The primary outcome is change in Oswestry disability index between baseline and 12 months after surgery. Secondary outcome measures are improvement of leg pain and changes in health related quality of life measured by the Euro-Qol-5D between baseline and 12 months after surgery, complications to surgery, duration of surgical procedures and length of hospital stay.

The Clinical Significance of Lumbosacral Transitional Vertebrae on the Surgical Outcomes of Lumbar Discectomy: A Retrospective Cohort Study of Young Adults

To evaluate whether the presence of lumbosacral transitional vertebrae (LSTV) affects the clinical outcomes of microdiscectomy (MD) in young adults with lumbar disc herniation. We retrospectively included 398 patients who were followed-up for at least 2 years after MD for lumbar disc herniation at L4/5 (disc above the LSTV). The patients were divided into 2 groups. Group A was made up of 31 patients in whom LSTV was detected. Group B, in contrast, was made up of 35 patients in whom LSTV was not detected. The LSTV were classified using plain radiographs and three-dimensional computed tomography by Castellvi etal. The primary outcome measure was pain intensity at each follow-up visit assessed with visual analog scale for back and leg. Secondary outcome measures included the Oswestry Disability Index, a 12-item short-form health survey for quality of life, complications, and recurrence rate. After surgery, the visual analog scale scores for the back and leg decreased significantly in both groups. However, the back pain intensity in group A worsened at 12 and 24 months postoperatively. The Oswestry Disability Index scores and 12-item short-form health survey (both mental and physical) worsened at 12 and 24 months postoperatively in group A. Two cases of reherniation (6.5%) were observed in group A, who required reoperation. LSTV can limit a patient's clinical improvement after MD with regard to pain intensity and recurrence. Caution must be taken when a patient is scheduled to undergo surgery.

Serum creatine phosphokinase levels as an indicator of muscle injury following lumbar disc surgery: Comparison of fully endoscopic discectomy and microdiscectomy

ObjectiveThe aim of this study is to make a comparison between fully endoscopic lumbar discectomy (FELD) and conventional microdiscectomy (MD) by using pre- and postoperative serum creatine phosphokinase (CPK) levels in correlation with postoperative low-back pain. MethodsFortyfive consecutive patients who underwent surgery for lumbar disc herniation were allocated into three groups with 15 patients on each: (1) FELD with interlaminar approach (IL), (2) FELD with transforaminal approach (TF), (3) Conventional MD. Serum CPK levels pre- and 1, 6, 12 and 24h postoperatively, patients’ body mass index (BMI), operation duration and hospital stays were recorded. The low-back pain pre- and postoperatively was assessed with the use of the 100mm visual analog scale (VAS) and the “Oswestry Disability Index” (ODI). ResultsThere were 16 female (35.5%) and 29 male (64.5%) patients with a mean age of 44.1 years. CPK levels at 6th, 12th and 24th hours postoperatively were found significantly lower in TF and IL groups compared to MD group (p<0.004). Mean operation duration was significantly shorter in MD group (p: 0.014). There was a significant decrease in both the VAS and ODI scores after the surgery in all patient groups (p<0.001). Postoperative VAS scores were found significantly higher in MD group (p: 0.04). ConclusionMinimal invasive nature of FELD procedures compared to the MD was substantiated by serum CPK levels in this study. To draw definitive conclusions regarding pain relief, larger patient samples should be evaluated, although postoperative VAS scores were found in favor of FELD.

Microdiscectomy or tubular discectomy: Is any of them a better option for management of lumbar disc prolapse

Objectives:Various types of minimally invasive techniques have been developed for the treatment of lumbar disc herniation. The original laminectomy was refined into microdiscectomy (MD). MD is the gold standard in management of lumbar disc herniation and is used as a yardstick for comparison with newer procedures such as tubular discectomy. So far, no studies have been reported in Indian population comparing tubular discectomy and microdiscectomy. The aim of this study was to compare immediate postoperative and 1-year outcome of patients undergoing tubular discectomy with those undergoing MD and to evaluate the learning curve as well as complication rates of tubular discectomy.Materials and Methods:Forty-six patients of MD and 102 (48 early and 54 late) patients of tubular discectomy (TD) were operated at Indian Spinal Injuries Centre, which is a tertiary level center between July 2009 and January 2012. They were studied for the following data: Baseline characteristics, visual analog scale (VAS) for leg pain and back pain, Oswestry Disability Index (ODI) scores, length of hospital stay, time taken to return to work, duration of surgery, intra- and post-operative complications, and reoperation rates.Results:The VAS score for leg pain, back pain, and ODI scores showed improvement in both groups during the 1st year after surgery. Time taken to return to work and mean hospital stay was shorter in case of TD as compared to MD group. The mean duration of surgery was 34 min shorter for conventional MD. The incidence of dural tear was 6.5% in MD group and 10.4% in early TD and decreased to 7.4% in late TD group.Conclusion:This study revealed that rate of recovery is significantly faster for TD as compared to conventional MD. In contrast, we encountered fewer complications in MD approach as compared to TD which although were not statistically significant and which also decreased as we gained experience.

Lumbar Endoscopic Microdiscectomy: Where Are We Now? An Updated Literature Review Focused on Clinical Outcome, Complications, and Rate of Recurrence.

Endoscopic disc surgery (EDS) for lumbar spine disc herniation is a well-known but developing field, which is increasingly spreading in the last few years. Rate of recurrence/residual, complications, and outcomes, in comparison with standard microdiscectomy (MD), is still debated and need further data. We performed an extensive review based on the last 6 years of surgical series, systematic reviews, and meta-analyses reported in international, English-written literature. Articles regarding patients treated through endoscopic transforaminal or interlaminar approaches for microdiscectomy (MD) were included in the present review. Papers focused on endoscopic surgery for other spinal diseases were not included. From July 2009 to July 2015, we identified 51 surgical series, 5 systematic reviews, and one meta-analysis reported. In lumbar EDS, rate of complications, length of hospital staying, return to daily activities, and overall patients' satisfaction seem comparable to standard MD. Rate of recurrence/residual seems higher in EDS, although data are nonhomogeneous among different series. Surgical indication and experience of the performing surgeon are crucial factors affecting the outcome. There is growing but still weak evidence that lumbar EDS is a valid and safe alternative to standard open microdiscectomy. Statistically reliable data obtained from randomized controlled trials (better if multicentric) are desirable to further confirm these results.

A meta-analysis of interlaminar minimally invasive discectomy compared to conventional microdiscectomy for lumbar disk herniation

A meta-analysis was conducted to evaluate the evidence that compared the safety and efficacy of interlaminar minimally invasive discectomy (ILMI) and conventional microdiscectomy (MD) for treating lumbar disk herniation (LDH) patients and to develop GRADE based recommendations for using the procedures to treat LDH. Eleven studies, encompassing 1012 patients, met the inclusion criteria. Overall, the results of the meta-analysis indicated that there were significant differences between the two groups in blood loss (SMD=−0.93, 95% CI −1.84, −0.02; p=0.05), and the number of days stays in hospital (SMD=−0.79, 95% CI −1.55, −0.04; p=0.04). However, there were no significant differences in the short-term back visual analog scale (VAS) scores (SMD=−0.34, 95% CI −0.81, 0.14; p=0.16), the long-term back VAS scores (SMD=0.13, 95% CI −0.04, 0.30; p=0.14), the short-term leg VAS scores (SMD=0.14, 95% CI −0.01, 0.29; p=0.07), the long-term leg VAS scores (SMD=0.12, 95% CI −0.05, 0.30; p=0.17), the short-term Oswestry disability index (ODI) scores (SMD=0.01, 95% CI −0.14, 0.15; p=0.92), the long-term ODI scores (SMD=0.11, 95% CI −0.03, 0.25; p=0.14), and the incidence of complications (RR=1.22, 95% CI 0.88, 1.69; p=0.24). The results of this meta-analysis demonstrate that ILMI and MD are both safe and effective surgical procedures for treating LDH. Compared with MD, ILMI can shorten days in hospital, decrease the mounts of blood loss during surgery. However, the overall GRADE evidence quality was very low. Therefore, further validation is required, and medical institutions should conduct high-quality studies.

The comparative assessment of efficacy of endoscopic transforaminal microdiscectomy and open microdiscectomy in treatment of lumbar discs herniation

Introduction. Method of endoscopic transforaminal microdiscectomy (ETMDE) has it’s own supporters and opponents. We decided to compare efficacy of ETMDE and open microdiscectomy (MDE).Materials and methods. We analyzed treatment results in two groups of patients, similar in age, disease duration, hernia localization and size, severity of pain and radiculopathy. In 60 patients (group 1) ETMDE was performed, in 60 (group 2) — MDE. the Short-term results were evaluated in the period from 1 to 30 days after surgery.Results. Positive results were achieved in both groups, respectively, in 91.7 and 88.4% patients. However, early reoperations were performed significantly more often in group 1 — in 8.3% patients than in the group 2 — in 1.5%. In group 1 unsatisfactory results were due to hernias migration in cranial or caudal direction, in group 2 — due to hernias middle position. Rehabilitation terms after ETMDE was almost 3 times less than after MDE.Conclusion. ETMDE technique with proper patients selection and adequate surgeon’s experience as effective as MDE. Worse outcomes were due to hernias migration in cranial or caudal direction, but rehabilitation terms in general, three times less than after MDE.

Minimally invasive surgery for lumbar disc herniation: a systematic review and meta-analysis

Assessing the benefits of surgical treatments for sciatica is critical for clinical and policy decision-making. To compare minimally invasive (MI) and conventional microdiscectomy (MD) for patients with sciatica due to lumbar disc herniation. A systematic review and meta-analysis of controlled clinical trials including patients with sciatica due to lumbar disc herniation. Conventional microdiscectomy was compared separately with: (1) Interlaminar MI discectomy (ILMI vs. MD); (2) Transforaminal MI discectomy (TFMI vs. MD). Back pain, leg pain, function, improvement, work status, operative time, blood loss, length of hospital stay, complications, reoperations, analgesics and cost outcomes were extracted and risk of bias assessed. Pooled effect estimates were calculated using random effect meta-analysis. Twenty-nine studies, 16 RCTs and 13 non-randomised studies (n=4,472), were included. Clinical outcomes were not different between the surgery types. There is low quality evidence that ILMI takes 11min longer, results in 52ml less blood loss and reduces mean length of hospital stay by 1.5days. There were no differences in complications or reoperations. The main limitations were high risk of bias, low number of studies and small sample sizes comparing TF with MD. There is moderate to low quality evidence of no differences in clinical outcomes between MI surgery and conventional microdiscectomy for patients with sciatica due to lumbar disc herniation. Studies comparing transforaminal MI with conventional surgery with sufficient sample size and methodological robustness are lacking.

Systematic review of microendoscopic discectomy for lumbar disc herniation

Systematic review. To search and analyse randomised controlled trials (RCTs) published since the Cochrane review by Gibson and Waddell (2007) comparing microendoscopic discectomy (MED) with open discectomy (OD) or microdiscectomy (MD) and to assess whether MED improves patient-reported outcomes. Discectomy for symptomatic herniated lumbar discs is an effective operative treatment. A number of operative techniques exist including OD, MD, and MED. A 2007 Cochrane review identified OD as an effective treatment for symptom improvement, and found sufficient evidence for MD. However, evidence for MED was lacking. A systematic review of Medline and Embase was carried out. Aiming to identify RCTs carried out after 2007, which compared OD with MD and MED which reported the Oswestry disability index (ODI) as an outcome. Four RCTs were identified. None of the studies found a significant difference in the ODI scores between study groups at any time point. Three studies compared MED to OD and one compared OD, MD, and MED. The largest study reported an increased number of severe complications in the MED group. There is some evidence to suggest that MED performed by surgeons skilled in the technique in tertiary referral centres is as effective as OD.