Open Discectomy Group Research Articles

Comparison of Percutaneous Endoscopic Transforaminal Discectomy, Chemonucleolysis, Microdiscectomy, and Microendoscopic Discectomy for Symptomatic Lumbar Disc Herniation: One-year Follow-up Clinical Results and Disc Degeneration.

This study compared the 1-year clinical outcomes and disc degeneration rates after transforaminal full-endoscopic lumbar discectomy (TF-FED), condoliase injection, open discectomy (OD), and microendoscopic discectomy (MED) for lumbar disc herniation (LDH). In total, 279 patients with LDH were divided into four treatment groups: TF-FED, OD, MED, and condoliase injection. Outcomes were evaluated on the basis of the complication rate, Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), visual analog scale (VAS) scores, and the modified MacNab criteria. Surgical and hospital costs were assessed. Disc degeneration and endplate bone marrow edema were evaluated using magnetic resonance images. The mean postoperative JOABPEQ, VAS, or modified MacNab scores among the four groups had no significant differences. Additionally, the nerve injury or reoperation rate among the TF-FED, OD, and MED groups had no significant difference. However, the reoperation rate with condoliase injection was high because of residual disc herniation. Surgical and hospital costs were lower with condoliase injection and higher with OD and MED than those with TF-FED. With TF-FED and condoliase injection, the Pfirrmann grade progressed, and the disc height was significantly smaller than that with OD and MED. Endplate bone marrow edema was more common with condoliase injection and TF-FED. All groups had good outcomes. TF-FED and condoliase injection may reduce the burden of surgery because they can be performed under local anesthesia with little blood loss and low medical costs but tend to be associated with disc degeneration and endplate bone marrow edema. A randomized controlled study with a larger sample is needed.

Micro-Endoscopic Discectomy versus Open Discectomy: A Struggle for Better Clinical Outcomes

Objective: The objective of the current study was to compare the clinical outcomes of a micro-endoscopic discectomy with an open discectomy.
 Materials & Methods: This Quasi-experimental study was conducted in the Department of Neurosurgery, Alrazi Healthcare, Lahore, and Ammar Medical Complex, Lahore. The sample consisted of 40 patients with lower back pain with radiation to the lower limbs. A lumbar disc single-segment hernia was diagnosed based on magnetic resonance imaging (MRI) findings. Independent sample t-test was used to explore the difference in outcomes and level of pain between group A and group B. Chi-square test was used to compare the recovery rate of patients in both groups.
 Results: A significant difference between the two groups in terms of surgery duration (t = 15.977, P = .000), blood loss during surgery (t = -10.256, P = .000), length of incision (t = -58.355, P = .000), and hospital stay after surgery (t = -4.687, P = .000) was found. The overall recovery rate for the micro-endoscopic Discectomy group was 95% whereas, in the open discectomy group, it was 90%.
 Conclusion: Micro-endoscopic discectomy is superior to open discectomy in terms of lesser surgical trauma, lesser blood loss, lesser hospital stay, earlier return to work, and higher pain resolution.

Quantitative Evaluation of the Trauma of CT Navigation PELD and OD in the Treatment of HLDH: A Randomized, Controlled Study

More evidence is required to support that computerized tomography navigation percutaneous spinal endoscopy in the treatment of highly migrated lumbar disc herniation is a more minimally invasive surgery than open discectomy . To quantitatively evaluate the efficacy and minimal invasiveness of computerized tomography navigation percutaneous spinal endoscopy and open discectomy in highly migrated lumbar disc herniation. A prospective randomized study. First Affiliated Hospital of Gannan Medical College. From August 2016 to February 2020, 68 patients with highly migrated lumbar disc herniation had undergone discectomy. Thirty-five of them randomly received computerized tomography (CT) navigation percutaneous spinal endoscopy at the pain department (CT navigation percutaneous spinal endoscopy group), and 33 patients received open discectomy at the orthopedics department (open discectomy group). The Visual Analog Scale (VAS) score, Japanese Orthopaedic Association (JOA) score, and modified MacNab criteria were applied to evaluate the clinical situations pre- and post-operation. The serum concentrations of IL-6, TNF-alpha, creatine phosphokina (CPK), and C-reactive protein (CRP) in the 2 groups were quantitatively measured. The postoperative VAS scores of the back and lower extremity were lower than those pre-operation in both groups, while the VAS score of back pain in the open discectomy group was significantly higher than that in the CT navigation percutaneous spinal endoscopy group at one week post-operation (P < 0.01). The postoperative JOA scores were significantly higher than those pre-operation in both groups. The serum concentrations of IL-6, TNF-alpha, CPK, and CRP in the open discectomy group were higher than those in the computerized tomography navigation percutaneous spinal endoscopy group postoperatively (P < 0.01). This is a single-center randomized study and with the limitation of the sample size. CT navigation percutaneous spinal endoscopy is a more minimally invasive surgery than open discectomy.Certificate number for the medical institution conducting the clinical trials for humans in China: 934.

Is Full Endoscopic Lumbar Discectomy Less Invasive Than Conventional Surgery? A Randomized MRI Study

In the present randomized prospective study, we compared the surgical invasiveness using a quantitative volumetric analysis of postoperative paravertebral muscle signal intensity changes between transforaminal full endoscopic lumbar discectomy (FELD) and open discectomy (OD). We prospectively collected the data from 50 patients with a single-level lumbar foraminal herniation, invalidating radicular pain, and adequate imaging studies available (postoperative magnetic resonance imaging [MRI] <24 hours). These patients had been randomly assigned to FELD (n= 25) or OD (n= 25). Data were collected on age, sex, leg and back pain, complications, and follow-up time. Muscle segmentations were performed manually using 3DSlicer software on postoperative isovolumetric T1-weighted contrast-enhanced and T2-weighted short tau inversion recovery MRI scans. Both sequences were processed using multiplanar reconstruction in orthogonal planes. The clinical and demographic characteristics and volumetric data were then compared between the 2 groups. We found a higher mean volume of paravertebral muscle signal alterations among the OD-treated patients in both T2-weighted short tau inversion recovery MRI (P ≤ 0.001) and T1-weighted contrast-enhanced MRI (P≤ 0.001) scans than among the FELD-treated patients. No differences were found between the median preoperative and postoperative leg pain between the 2 groups (P=1.000). The median scores for postoperative back pain were significantly lower for the FELD group (P ≤ 0.001), as was the median interval from surgery to autonomous mobilization (P= 0.001). We found a significant difference in signal intensity of the paravertebral muscles between the FELD and OD groups, reflective of the minor surgical invasiveness of endoscopic discectomy. FELD resulted in less trauma to the paraspinal muscles, possibly also reducing inflammatory cytokine release and, therefore, is a valuable tool for spinal surgeons.

Does the microendoscopic technique reduce mortality and major complications in patients undergoing lumbar discectomy? A propensity score-matched analysis using a nationwide administrative database.

OBJECTIVE Although minimally invasive spinal surgery has recently gained popularity, few nationwide studies have compared the adverse events that occur during endoscopic versus open spinal surgery. The purpose of this study was to compare perioperative complications associated with microendoscopic discectomy (MED) and open discectomy for patients with lumbar disc herniation. METHODS The authors retrospectively extracted from the Diagnosis Procedure Combination database, a national inpatient database in Japan, data for patients admitted between July 2010 and March 2013. Patients who underwent lumbar discectomy without fusion surgery were included in the analysis, and those with an urgent admission were excluded. The authors examined patient age, sex, Charlson Comorbidity Index, body mass index, smoking status, blood transfusion, duration of anesthesia, type of hospital, and hospital volume (number of patients undergoing discectomy at each hospital). One-to-one propensity score matching between the MED and open discectomy groups was performed to compare the proportions of in-hospital deaths, surgical site infections (SSIs), and major complications, including stroke, acute coronary events, pulmonary embolism, respiratory complications, urinary tract infection, and sepsis. The authors also compared the hospital length of stay between the 2 groups. RESULTS A total of 26,612 patients were identified in the database. The mean age was 49.6 years (SD 17.7 years). Among all patients, 17,406 (65.4%) were male and 6422 (24.1%) underwent MED. A propensity score-matched analysis with 6040 pairs of patients showed significant decreases in the occurrence of major complications (0.8% vs 1.3%, p = 0.01) and SSI (0.1% vs 0.2%, p = 0.02) in patients treated with MED compared with those who underwent open discectomy. Overall, MED was associated with significantly lower risks of major complications (OR 0.62, 95% CI 0.43-0.89, p = 0.01) and SSI (OR 0.29, 95% CI 0.09-0.87, p = 0.03) than open discectomy. There was a significant difference in length of hospital stay (11 vs 15 days, p < 0.001) between the groups. There was no significant difference in in-hospital mortality between MED and open discectomy. CONCLUSIONS The microendoscopic technique was associated with lower risks for SSI and major complications following discectomy in patients with lumbar disc herniation.

Comparison of Open Discectomy with Microendoscopic Discectomy in Lumbar Disc Herniations: Results of a Randomized Controlled Trial

Introduction Despite all of the technical refinements, surgical treatment of herniated discs still remains controversial. The objective of the current prospective randomized study was to compare the outcome of patients with persistent sciatica secondary to lumbar disc herniation treated with either open discectomy (OD) or microendoscopic discectomy (MED) technique. Patients and Methods We performed a prospective controlled randomized study of 40 patients with sciatica caused by lumbar disc herniations nonresponsive to conservative treatment who underwent OD or MED with a 24-month follow-up period. Pre- and postoperative neurological status, pain, and functional outcome were evaluated. Other studied variables were the duration of the procedure, blood loss, time of hospital stay, and time to return to work. Statistical analysis with a p value less than 0.005 was performed. Results The only statistically significant differences found were for size of the incision, length of hospital stay, and operative time. The former two were greater in the OD group ( p &lt; 0.01 and p = 0.05, respectively), and the latter was greater in the MED group ( p &lt; 0.01). Conclusion The few parameters that were found to be statistically significant between the groups did not affect the overall outcome. In the current series, the final clinical and neurological results were similarly satisfactory in both the OD and the MED groups.

The efficacy of minimally invasive discectomy compared with open discectomy: a meta-analysis of prospective randomized controlled trials

Advocates of minimally invasive discectomy (MID) have promoted this operation as an alternative to open discectomy (OD), arguing that there may be less injury to the paraspinal muscles, decreased postoperative pain, and a faster recovery time. However, a recently published large randomized controlled trial (RCT) comparing these approaches reported inferior relief of leg pain in patients undergoing MID. The authors conducted a meta-analysis to evaluate complications and improvement in leg pain in patients with radiculopathy enrolled in RCTs comparing OD to MID. The authors performed a literature search using Medline and EMBASE of studies indexed between January 1990 and January 2011. Predetermined RCT eligibility included the usage of tubular retractors during MID, a minimum follow-up duration of 1 year, and quantification of pain with the visual analog scale (VAS). Trials that only evaluated patients with recurrent disc herniation were excluded. Data on operative parameters, complications, and VAS scores of leg pain were extracted by 2 investigators. A meta-analysis was performed assuming random effects to determine the difference in mean change for continuous outcomes and the risk ratio for binary outcomes. Six trials comprising 837 patients (of whom 388 were randomized to MID and 449 were randomized to OD) were included. The mean operative time was 49 minutes during MID and 44 minutes during OD; this difference was not statistically significant. Incidental durotomies occurred significantly more frequently during MID (5.67% compared with 2.90% for OD; RR 2.05, 95% CI 1.05-3.98). Intraoperative complications (incidental durotomies and nerve root injuries) were also significantly more common in patients undergoing MID (RR 2.01, 95% CI 1.07-3.77). The mean preoperative VAS score for leg pain was 6.9 in patients randomized to MID and 7.2 in those randomized to OD. With long-term follow-up (1-2 years postoperatively), the mean VAS score improved to 1.6 in both the MID and OD cohorts. There was no significant difference in relief of leg pain between the 2 approaches with either short-term follow-up (2-3 months postoperatively, 0.81 points on the VAS, 95% CI -4.71 to 6.32) or long-term follow-up (2.64 on the VAS, 95% CI -2.15 to 7.43). Reoperation for recurrent herniation was more common in patients randomized to the MID group (8.50% compared with 5.35% in patients randomized to the OD group), but this difference was not statistically significant (RR 1.56, 95% CI 0.92-2.66). Total complications did not differ significantly between the operations (RR 1.50, 95% CI 0.97-2.33). The current evidence suggests that both OD and MID lead to a substantial and equivalent long-term improvement in leg pain. Adequate decompression, regardless of the operative approach used, may be the primary determinant of pain relief-the major complaint of many patients with radiculopathy. Incidental durotomies occurred significantly more frequently during MID, but total complications did not differ between the techniques.

Comparison of Lumbar disc herniation surgery by two different methods

Objective To compare the clinical value of approach of microendoscopic discectomy( MED) and open discectomy (OD) in patients with lumbar disc herniation (LDH). Methods 100 patients with lumbar disc herniation according to the different surgical approaches were divided into MED group (n =50) and OD group (n =50) , The indicators of blood loss,operative time,hospitalization time,nerve root injury,relieve sciatica were observed in two groups. Results The rate of excellent in MED group (90. 0% ) were higher than OD group (80. 0% ) (χ~2 = 3.99, P < 0. 05); The indicators of blood loss, operative time, hospitalization time in MED group were less than OD group (t = 2.412,t=2.498,<=2.518,t =2.416,all P<0.05). Conclusion Compared with OD group,MED offer a similar short-term clinical outcome,but with smaller incision,less tissue trauma and quicker recovery. Key words: Intervenebral disk displacement; Minimally invasive operation; Microsurgery

COMPARISON OF OPEN DISCECTOMY WITH MICROENDOSCOPIC DISCECTOMY IN LUMBAR DISC HERNIATIONS

We compared the intra- and postoperative differences, as well as the final outcome of patients with herniated lumbar discs who underwent either open discectomy (OD) or microendoscopic discectomy (MED). We performed a prospective controlled randomized study of 40 patients with sciatica caused by lumbar disc herniations nonresponsive to conservative treatment who underwent OD or MED with a 24-month follow-up period. Pre- and postoperative neurological status, pain, and functional outcome were evaluated. Other studied variables were the duration of the procedure, blood loss, time of hospital stay, and time to return to work. Statistical analysis with a P value less than 0.005 was carried out. The only statistically significant differences found were for size of the incision, length of hospital stay, and operative time. The former two were greater in the OD group (P < 0.01 and P = 0.05, respectively), and the latter was greater in the MED group (P < 0.01). The few parameters that were found to be statistically significant between the groups did not affect the overall outcome. In the current series, the final clinical and neurological results were similarly satisfactory in both the OD and the MED groups.

Interleukin-6 Protein Expression Is More Important Than Interleukin-6 mRNA Levels in Assessing Surgical Invasiveness

Interleukin-6 (IL-6) protein has been recognized as a sensitive marker of surgical stress response. However, little is known about the clinical significance of IL-6 mRNA levels as a marker of surgical stress. This study aims to examine the role of IL-6 mRNA expression in comparing the tissue invasiveness of microendoscopic discectomy (MED) and open discectomy (OD). Twenty-three consecutive patients were randomly selected to undergo either MED or OD. The total RNA was extracted from the peripheral whole blood of patients at pre-op and at 1, 2, 4, 8, 12 h post-op. The real-time reverse transcription polymerase chain reaction (RT-PCR) using the SYBR Green I fluorescence dye and the 2(-DeltaDeltaCt) method was adopted to measure the IL-6 gene expression. The quantitative changes of IL-6 mRNA expression in MED and OD patients at different times post-op differed significantly, P = 0.04. Experimental results indicate that the changes in IL-6 mRNA expression in OD and MED groups varied significantly at 1 h, 12 h post-op, 10.26-fold versus 4.42-fold and 52.15-fold versus 26.78-fold increase, respectively. Although IL-6 mRNA expression demonstrated an earlier difference than protein levels at 1 h post-op, IL-6 mRNA levels were found to be significantly affected after surgical procedures. Furthermore, compared with our enzyme-linked immunosorbent assay data, no significant correlation existed between IL-6 mRNA and protein levels at any post-op time interval. We conclude that IL-6 mRNA expression using RT-PCR to extract the total RNA from a patient's peripheral whole blood is more sensitive than protein levels but can be significantly affected by surgical procedures. The enzyme-linked immunosorbent assay data on IL-6 protein expression are more consistent and significant than IL-6 mRNA levels in comparing tissue invasiveness between MED and OD.

Less systemic cytokine response in patients following microendoscopic versus open lumbar discectomy

The magnitude of the tissue damage from surgery impacts the trauma response. This response is proportional to the severity of surgical stress. Systemic cytokines are recognized as markers of postoperative tissue trauma. Microendoscopic discectomy (MED) recently has become popular for treating lumbar disc herniations, and is associated with favorable clinical outcomes compared with open discectomy (OD). This study postulates that MED is a less traumatic procedure, and therefore has a lower surgical stress response compared to OD. In this study, a quantitative comparison of the overall effects of surgical trauma resulting from MED and OD was performed through analyzing patient systemic cytokines response. From April, 2002 to June, 2003, 22 consecutive patients who had symptomatic lumbar disc herniations were prospectively randomized to undergo either intracanalicular MED ( N = 10) or OD ( N = 12). In this study, the Vertebroscope System (Zeppelin, Pullach, Germany) was used to perform the endoscopic discectomy procedure in all MED patients. Serum levels of tumor necrosis factor-α (TNF-α), Interleukin-1β (IL-1β), Interleukin-6 (IL-6), and Interleukin-8 (IL-8) were measured before surgery and at 1, 2, 4, 8 and 24 h after surgery using an enzyme-linked immunosorbent assay. Serum C-reactive protein (CRP) was measured at the same time interval. The results showed the MED patients had shorter postoperative hospital stay (mean, 3.57 ± 0.98 vs. 5.92 ± 2.39 days, p = 0.025) and less intraoperative blood loss (mean, 87.5 ± 69.4 vs. 190 ± 115 ml, p = 0.042). The operating length, including the set-up time, was longer in the MED group (mean, 109 ± 35.9 vs. 72.1 ± 17.8 min, p = 0.01). The mean size of skin incision made for the MED patients was 1.86 ± 0.13 cm (range 1.7–2.0 cm); and 6.3 ± 0.98 cm for the OD patients (range 5.5–8 cm), p = 0.001. The patients’ pain severity of the involved limbs on 10-point Visual Analog Scale before operation in MED group was 7.5 ± 0.3 (range 6–9) and 8 ± 0.2 (range 7–9) in OD group, p = 0.17; and after surgery, 1.5 ± 0.2 (range 1–2) in MED group and 1.4 ± 0.1 (range 1–3) in OD group, p = 0.91. CRP levels peaked at 24 h in both groups, and OD patients displayed a significantly greater postoperative rise in serum CRP (mean, 27.78 ± 15.02 vs. 13.84 ± 6.25 mg/l, p = 0.026). Concentrations of TNF-α, IL-1β, and IL-8 were detected only sporadically. Serum IL-6 increased less significantly following MED than after OD. In the MED group, IL-6 level peaked 8 h after surgery, with the response statistically less than in the open group (mean, 6.27 ± 5.96 vs. 17.18 ± 11.60 pg/ml, p = 0.025). A statistically significant correlation was identified between IL-6 and CRP values ( r = 0.79). Using the modified MacNab criteria, the clinical outcomes were 90% satisfactory (9/10) in MED patients and 91.6% satisfactory (11/12) in OD patients at a mean 18.9 months (range 10–25) follow-up. Based on the current data, surgical trauma, as reflected by systemic IL-6 and CRP response, was significantly less following MED than following OD. The difference in the systemic cytokine response may support that the MED procedure is less traumatic. Moreover, our MED patients had achieved satisfactory clinical outcomes as the OD patients at a mean 18.9 months follow-up after surgery.