Discectomy Research Articles

Safety and Efficacy of Percutaneous Lumbar Discectomy and Percutaneous Disc Cementoplasty for Painful Lumbar Disc Herniation in Patients over 60 Years

PurposeTo determine the safety and efficacy of percutaneous lumbar discectomy (PLD) and percutaneous disc cementoplasty (PDCP) for painful lumbar disc herniation (LDH) in patients >60 years of age. Materials and MethodsSixteen older patients (mean age, 71.00 ± 6.24 years) with painful LDH were treated with PLD and PDCP. The outcome data (the Macnab criteria, visual analog scale score, and Oswestry disability index) were collected preoperatively; at 1 week postoperatively; at posttreatment months 1, 3, and 6; and every 6 months thereafter. In addition, treatment duration, injection volume of bone cement, length of hospital stay, and complications were assessed. ResultsTreatment was successful in all patients. The pain relief rate at the last follow-up was 87.5%. Six, 8, and 2 patients showed excellent, good, and fair results, respectively; no patient showed a poor result. The average visual analog scale for back and leg pain decreased from 6.75 ± 1.06 and 7.00 ± 0.89 before the procedure to 2.81 ± 1.60 and 2.87 ± 1.75 at 1 month, 2.79 ± 1.58 and 2.71 ± 1.64 at 6 months, and 2.90 ± 1.73 and 3.00 ± 1.76 at 1 year, respectively. The scores were 2.44 ± 1.63 and 2.44 ± 1.71, respectively, at the last follow-up. The Oswestry disability index also changed after the procedure, with significant differences between baseline scores and those at each follow-up (P < .001). The mean procedure duration, injection volume of bone cement, and length of hospital stay were 55.69 ± 5.86 minutes, 2.50 ± 0.63 mL, and 7.06 ± 2.41 days, respectively. There were no complications. ConclusionsThe combination of PLD and PDCP is feasible, safe, and effective for older patients with painful LDH.

Retrospective study of the interlaminar approach for percutaneous endoscopic lumbar discectomy with the guidance of pre-operative magnetic resonance neurography.

To measure the direct effects of pre-operative magnetic resonance neurography (MRN), and analyze the procedure and clinical outcomes of the percutaneous endoscopic interlaminar discectomy, in order to demonstrate the feasibility and safety of the interlaminar approach. In this study, 127 patients who underwent percutaneous endoscopic lumbar discectomy (PELD) and were followed up by more than 12 months, were retrospectively evaluated. The pre-operative demographic data were collected. In addition, the coronal scan and the reconstruction of the lumbosacral plexus were examined to measure the distance between the nerve root and the dural sac at the coronal plane. Furthermore, the post-operative and pre-operative visual analog scale (VAS) scores and Oswestry Disability Index (ODI) were compared. The mean and minimum values of distance T between the nerve root and dural sac of L5/S1 to L2/3 on the operation side of the MRN images were all larger than 7.3 mm which is the diameter of the working canal. During the follow-up, VAS and ODI data improved significantly compared with their corresponding pre-operative scores (P<0.01). Regarding the post-operative complications, there were 2 (1.57%) cases of hypesthesia and 3 (2.36%) cases of neuropathic pain, which were transient and alleviated in 3 months. In addition, there was 1 (0.79%) case of intervertebral space infection and 1 (0.79%) dural tear. No relapse of disc herniation and iatrogenic instability occurred by the end of the last follow-up. The MRN indicates that the incidence of herniated disc impingement increases over the distance between the nerve root and the dural sac, thus making the interlaminar approach more suitable for the treatment of herniation. The procedures and clinical outcomes of the IL-PELD demonstrate the safety and advantages of the interlaminar approach.

Traditional versus Percutaneous Transforaminal Endoforaminal Discectomy Effect on the Nervous System Function and Serum LEK, GFAP and PGE-2 in Patients with Senile Lumbar Spinal Stenosis.

To compare the influence of percutaneous transforaminal endoscopic discectomy (PTED) and traditional operation on the nervous system function and the serum leu-enkephalin (LEK), glial fibrillary acidic protein (GFAP) and prostaglandin E-2 (PGE-2) in patients with senile lumbar spinal stenosis. Experimental study. Department of Orthopedics Two, Xinjiang Changji Hui Autonomous Prefecture People's Hospital, Xinjiang, China, from March 2017 to March 2018. A total of 146 patients with senile lumbar spinal stenosis were randomly divided into control group and observation group, 73 in each group. Control group underwent traditional operation, while the observation group underwent PTED. General situation of operation, serum LEK, GFAP, PGE-2, American Spinal Injury Association (ASIA) score and Japanese Orthopaedic Association (JOA) score were compared. Intraoperative blood loss in observation group was less than that in control group (p<0.001). Both operation time and length of hospital stay in observation group were shorter than those in control group (both p<0.001). At 24 hours later after operation, both levels of serum LEK and ASIA score in observation group were higher than those in control group (p=0.006 and p<0.001, respectively), and levels of serum GFAP and PGE-2 and JOA score in observation group were all lower than those in control group (all p<0.001). Compared with traditional operation, PTED has the advantages of less intraoperative blood loss, shorter operation time and length of hospital stay, etc. Besides, PTED can effectively reduce serum LEK, BFGF and PGE-2 expression in patients; and dramatically improve their nervous system function and lumbar function.

Percutaneous Endoscopic Thoracic Discectomy in the Upper and Midthoracic Spine: A Technical Note.

Despite the successful application of percutaneous endoscopic thoracic discectomy (PETD), its technical feasibility and outcomes for symptomatic upper and midthoracic disc herniation have not been reported yet. The purpose of this article was to evaluate the feasibility of the percutaneous transforaminal endoscopic approach to remove disc herniations in the upper and midthoracic spine. Fourteen consecutive patients (mean age, 42.4 years; 12 males, 2 females) who underwent PETD were included in the analysis. The procedure was performed under local anesthesia and intravenous sedation using the standard endoscopy instrument set. The transforaminal approach combined with foraminoplasty was used to access the herniated areas. Treatment outcomes were evaluated using visual analogue scale (VAS) scores, Oswestry Disability Index (ODI) scores, and the modified MacNab criteria. Four discectomies were performed at T2–3, 5 at T3–4, and 5 at T5–6. The mean follow-up period was 43.4 months, and all patients showed statistically significant postoperative improvement (VAS: 7.3 to 2.3, ODI: 53.5 to 16.9, p<0.05 for all). No serious complications were reported during follow-up. PETD for upper and midthoracic disc herniation is a feasible and effective minimally invasive treatment option with favorable clinical results.

Does Preservation of Ligamentum Flavum in Percutaneous Endoscopic Lumbar Interlaminar Discectomy Improve Clinical Outcomes?

ObjectiveLigamentum flavum (LF) is an important anatomical structure for prevention of postoperative adhesions, but the opening of LF is necessary for percutaneous endoscopic lumbar interlaminar discectomy (PEID). Although the defect in LF is small with conventional PEID, the defect could be minimized with LF splitting technique. The objective of this study was to compare clinical outcomes of PEID with opening of LF versus splitting of LF. MethodsA retrospective study was performed for patients underwent PEID for L5–S1. PEID with the opening of LF (open-group) was performed for 55 patients and with splitting of LF (split-group) was performed for 34 patients. The defect of LF in Open-group was 3–5 mm, but the defect was negligible in split-group because the split LF was reapproximated by its elasticity. Clinical outcomes were evaluated with Korean version of the Oswestry Disability Index (K-ODI) and visual analogue pain scores for back (VASB) and leg (VASL). The changes of clinical outcomes during postoperative 24 months between groups were evaluated with linear mixed-effects model. ResultsThe clinical outcomes were similar between groups for K-ODI (p=0.98), VASB (p=0.52), and VASL (p=0.59). Each outcome demonstrated significant improvement from preoperative baseline throughout the postoperative 24 months (p<0.05). Complications included recurrence in 4 patients and dural tear in 1 in open-group (9.1%), and residual disc herniation in 2 patients and transient weakness in 1 in split-group (8.8%). ConclusionSplitting versus opening LF in PEID may be left to the surgeon’s discretion. The potential risks and benefits of LF handling should be considered when performing this surgical technique in PEID.

Percutaneous Transforaminal Endoscopic Discectomy versus Micro-Endoscopic Discectomy for Lumbar Disc Herniation

BackgroundPercutaneous transforaminal endoscopic discectomy (PTED) and micro-endoscopic discectomy (MED) are alternative minimally invasive, widely performed procedures for the treatment of lumbar disc herniation (LDH). This study compared the clinical outcomes of these 2 surgical techniques in treating LDH.Material/MethodsA comprehensive literature search was performed in PubMed, MEDLINE, EMBASE, Cochrane, and Google Scholar to identify all relevant studies comparing PTED and MED in treating LDH.ResultsEight comparative studies assessing a total of 805 patients were included for the final analysis. The results indicated that PTED needs a shorter incision [−1.02 (−1.21 to −0.83), p<0.001], less time in bed [−2.14 (−3.34 to −0.94), p<0.001], and shorter hospital stay [−1.92 (−2.90 to −0.94), p<0.001], whereas MED is superior regarding intraoperative fluoroscopy [7.47 (2.78 to 12.17), p=0.002] and total cost [0.69 (0.38 to 1.00), p<0.001]. No significant differences were found on operation time, intraoperative blood loss, or complications. Significant lower back pain was found in the PTED group at 1 week postoperatively [−0.52 (−0.95 to −0.10), p=0.02] and 1 year postoperatively or the last follow-up [−0.41 (−0.76 to −0.06), p=0.02]; significant lower leg pain was also detected at 1 week postoperatively [−0.52 (−0.75 to −0.30), p<0.001]. Oswestry Disability Index (ODI) was significant better at 1 week postoperatively in the PTED group [−4.41 (−7.03 to −1.79), p=0.001]. No significant differences were detected at other time points regarding pain score and ODI.ConclusionsBoth PTED and MED are safe and effective techniques for treating LDH. However, taking all clinical outcomes together, PTED might be a preferable treatment modality for LDH.

Toxicity Effects of Methylene Blue on Rat Intervertebral Disc Annulus Fibrosus Cells

Background: There is an increasing local application of methylene blue (MB) in the treatment of discogenic low back pain (LBP) and percutaneous transforaminal endoscopic discectomy (PTED) procedures. MB could generate DNA damage and induce apoptosis in different cell types; however, the effects of MB on intervertebral disc (IVD) annulus fibrosus (AF) cells are not clearly understood. Objective: The objective of this study was to investigate the effects of different concentrations of MB on rat AF cells in vitro. Study Design: This study used an experimental design. Setting: This research was conducted at the Orthopaedic Institute of the Clinical Medical College of Yangzhou University. Methods: AF cells were isolated and cultured with different concentrations of MB (0, 2, 20, and 200 μg/mL) and assessed to determine the possible cytotoxic effects of MB. The cell proliferation was detected by Cell Counting Kit-8 (CCK-8) assay. The inverted phase-contrast microscopy was used to perform morphological observation of apoptotic cells, and flow cytometry was used to measure the incidence of cell apoptosis. The mRNA and protein expression levels of apoptosis-associated genes (caspase-3, Bcl-2, and Bax) and other related genes (collagen type I, transforming growth factor β1 [TGF-β1], fibroblast growth factor [bFGF], and tissue inhibitor of metalloproteinase-1 [TIMP-1]) were analyzed by quantitative real-time PCR (RT-PCR) and Western blotting. Results: Our results indicated that MB reduced cell viability in a concentration- and timedependent manner. MB also induced marked AF cell apoptosis in a concentration-dependent manner observed by inverted phase-contrast microscopy, flow cytometry, and indicated by the increased expression of caspase-3. Both RT-PCR and Western blotting revealed significant upregulation of Bax and caspase-3 expression levels accompanied by decreased expression of Bcl2 in a concentration-dependent manner. Moreover, collagen type I, TGF-β1, bFGF, and TIMP-1 mRNA and protein levels were also found to be decreased by MB in a concentration-dependent manner. Limitations: Limitations of this study were the in vitro study design and lack of in vivo validation of the observed effects of MB on human IVD cells. Conclusions: Our results indicate that a high concentration of MB can not only inhibit proliferation and paracrine function of AF cells, but can also induce cell apoptosis in a concentration-dependent manner, suggesting that it is necessary to choose low concentrations of MB in practical application and limit the use of MB in the treatment of discogenic LBP to research protocols. Key words: Methylene blue, annulus fibrosus cell, proliferation, apoptosis, paracrine

Using Percutaneous Endoscopic Outside-In Technique to Treat Selected Patients with Refractory Discogenic Low Back Pain

Background: Controversy is not uncommon in the diagnosis of discogenic low back pain (DLBP) and in the identification of the location of the pain source for the symptomatic disc in patients with DLBP. Various techniques, from minimally invasive procedures to fusion surgery, are used to treat chronic DLBP, but the clinical outcomes are variable. Percutaneous endoscopic discectomy by transforaminal or interlaminar approach is considered to be an effective method to treat DLBP, but the evidence is limited; the lack of clear evidence may be associated with patient selection and surgical technique. Objectives: The purpose of this study is to evaluate the clinical results of percutaneous endoscopic treatment for annular tear in selected patients with DLBP by using the outside-in technique. Study Design: A prospective study and retrospective observations were performed on 24 consecutive patients with a minimum 2 years of follow-up. This study was approved by the Institutional Review Board (IRB) of Buddhist Dalin Tzu-Chi General Hospital Foundation (IRB number: 10504004) and written informed consent was obtained from all patients. Setting: This research took place within an interventional pain management and spine practice. Methods: Twenty-four consecutive patients with single-level DLBP diagnosed by positive highintensity zone on magnetic resonance imaging, positive provocative discography, and block test underwent a percutaneous endoscopic procedure from January 2014 to December 2015. The transforaminal approach or interlaminar approach was selected according to the location of the annular tear. The torn lesions were visualized directly and treated by puncture and debridement of the inflammatory tissues from the outer annulus fibrosus to the inner nucleus using the outsidein technique. The Visual Analog Scale (VAS) score and Oswestry Disability Index (ODI) score were evaluated before and after surgery. The clinical global outcomes were assessed on the basis of modified MacNab criteria. Results: These patients included 13 men and 11 women with a mean age of 43.8 years (range, 32-55 yrs). There were 15 lesion levels at L4/L5 and 9 lesion levels at L5/S1. Among them, 15 levels were accessed by transforaminal approach and 9 levels by interlaminar approach. No serious complications were observed during the follow-up periods. All except 2 patients experienced significant symptomatic and functional improvements at the 2-year follow-up with a success rate of 91.7%. Limitations: Significant limitations include nonrandom format and small sample size. Future research may focus on controlled prospective studies with larger sample sizes and long-term followup to examine the validity of this protocol. Conclusions: The percutaneous endoscopic procedure provides a safe and effective treatment for selected patients with DLBP. The outside-in technique allows the surgeons to visualize and treat the torn or inflammatory lesions directly, and the success rate is high at 2 years follow-up. Key words: Transforaminal, interlaminar, outside-in technique, endoscopic discectomy, discogenic low back pain

Biomechanical comparison of percutaneous posterior endoscopic cervical discectomy and anterior cervical decompression and fusion on the treatment of cervical spondylotic radiculopathy

BackgroundCervical spondylotic radiculopathy is a common spinal disease. The traditional surgical treatment consists of anterior cervical decompression and fusion (ACDF), but it presents problems such as trauma and fusion complications. Percutaneous posterior endoscopic cervical discectomy (PPECD) is a new minimally invasive technology that has produced good clinical outcome, but further biomechanical comparisons are needed to guide the clinical work. The goal of this study was to compare the biomechanical characteristics of the two methods by finite element analysis.MethodOn the basis of the computed tomography scanning data of five cases of cervical spondylosis after PPECD surgery, five cases after ACDF surgery, and five non-surgical patients, software (Mimics 15.0, HyperMesh 12.0, and Abaqus 6.13) was adopted to establish a C1–C7 segment 3D finite element model. We also applied 50 N vertical load on the C1 surface and 1.5 Nm torque, simulated the anteflexion, rear protraction, and left and right lateral flexion and rotation, and observed the stability, stress distribution, and Cobb angular change of the surgical section of the cervical vertebra under different working conditions.ResultThe postoperative model under different working conditions demonstrated poorer stability than the non-surgical group, but the stability of the PPECD group was close to that of the non-surgical group. The stability of the ACDF group was the worst, especially when making lateral bending and posterior extension. The ACDF group also showed significant differences. The PPECD group showed uniform stress distribution, whereas the ACDF group was under large stress, which was primarily concentrated in the internal fixation system. In addition, the implant showed the potential for fracture. The Cobb angle of surgery section of the PPECD group was smaller than that of the ACDF group, and the stability of the section was good.ConclusionFrom the perspective of finite element analysis, the cervical vertebrae after PPECD treatment showed good biomechanical performance and stability.

Overview of risk factors for failed percutaneous transforaminal endoscopic discectomy in lumbar disc herniation

The lumbar disc herniation is a common and recurrent disease in the department of orthopedics. At present, the treatment means mainly include conservative treatment and surgical treatment. Compared with traditional open surgery, percutaneous transforaminal endoscopic discectomy (PTED) is safe, effective, economical and minimally invasive. It is widely used in minimally invasive treatment of lumbar disc herniation. However, the clinical reports of the failure of PTED are also common. According to the research reports of domestic and foreign scholars, there are varieties of risk factors for surgical failures, including the selections of patients, indications, surgical approaches and anesthesia methods preoperative. Occurrences of surgical complications including infection or left pains, and reasonable rehabilitation exercise after the operation are related to failures. There is no unified conclusion at present. In this paper, we reviewed the literatures about failed PTED, and try to make an overview about the general situation of failed operation in clinical practice, the risk factors for failures and the countermeasures.

Abandoned techniques in spine surgery.

In spine surgery, certain surgical techniques and devices are currently in marked decline or have been completely abandoned. Although used in thousands of patients, such treatments failed to demonstrate durable and sound effectiveness, and sometimes associate inacceptable morbidity. Chemopapain injections, percutaneous discectomy, laser discectomy or antiadhesion gels are examples of abandoned therapies. Some other techniques are in frank decline like implantation of interspinous devices or lumbar disc prosthesis. In general, a technique is abandoned due to inefficacy, excessive associated morbidity, substituted by another more efficacious and less aggressive technique, end of commercialization, or usage prohibition. In the last decades, a great commercial pressure plus an increasing social demand have managed to convince many spine surgeons to indicate treatments not sufficiently supported by scientific evidence nor consolidated over time, many of which are eventually abandoned.

Percutaneous endoscopic transforaminal discectomy precedes interlaminar discectomy in the efficacy and safety for lumbar disc herniation.

We searched several databases from the times of their inception to 20 December 2018. Randomized controlled trials and cohort studies that compared percutaneous endoscopic transforaminal discectomy (PETD) with percutaneous endoscopic interlaminar discectomy (PEID) were identified. We used a random-effects model to calculate the relative risks (RRs) of, and standardized mean differences (SMDs) between the two techniques, with 95% confidence intervals (CIs). Twenty-six studies with 3294 patients were included in the final analysis. Compared with PEID, PETD reduced the short-term (SMD −0.68; 95% CI −1.01, −0.34; P=0.000) and long-term (SMD −0.47; 95% CI −0.82, −0.12; P=0.000) visual analog scale scores, blood loss (SMD −4.75; 95% CI −5.80, −3.71; P=0.000), duration of hospital stay (SMD −1.86; 95% CI −2.36, −1.37; P=0.000), and length of incision (SMD −3.93; 95% CI −5.23, −2.62; P=0.000). However, PEID was associated with a lower recurrence rate (P=0.035) and a shorter operative time (P=0.014). PETD and PEID afforded comparable excellent- and good-quality data, long- and short-term Oswestry disability index (ODI) scores, and complication rates. PETD treated lumbar disc herniation (LDH) more effectively than PEID. Although PETD required a longer operative time, PETD was as safe as PEID, and was associated with less blood loss, a shorter hospital stay, and a shorter incision. PETD is the best option for patients with LDH.

Posterior percutaneous endoscopic cervical discectomy through lamina–hole approach for cervical intervertebral disc herniation

Background: The optimal PECD surgical approach for cervical intervertebral disc herniation (CIVDH) remains controversial. The conventional posterior K-hole approach for PECD leads to damage of facet joint.Objectives: This article is to first describe a novel posterior lamina–hole approach of percutaneous endoscopic cervical discectomy (PECD) for CIVDH. The objective of this study is to evaluate the feasibility and short-term clinical effect of this approach.Methods: Single-center retrospective observational study of all patients managed with posterior percutaneous endoscopic cervical discectomy (PPECD) using the lamina–hole approach for symptomatic single-level CIVDH between January 2015 and January 2016. The clinical outcomes were evaluated with the visual analog scale, modified MacNab criteria and radiographical results.Results: Twelve patients (seven women, five men) were enrolled in the study. Positive clinical response for pain relief was achieved in these patients receiving PPECD through lamina–hole approach for CIVDH. Postoperative MRI showed complete removal of the disc material in all the patients, no failure due to residual fragment was observed.Conclusion: As an alternative surgical approach of PPECD, PPECD through lamina–hole approach is a novel access for CIVDH and may be considered a valid and safe therapeutic option for CIVDH. The advantages of this approach are not only providing a valid and secure access to herniated cervical intervertebral fragment but also avoiding the iatrogenic damage to the facet joint and relevant functional spinal unit (FSU). Theoretically, the potential of secondary degeneration of FSU is low.

A Novel Posterior Trench Approach Involving Percutaneous Endoscopic Cervical Discectomy for Central Cervical Intervertebral Disc Herniation.

This report describes a novel posterior trench approach involving percutaneous endoscopic cervical discectomy (PECD) for central cervical intervertebral disc herniation (CIVDH) and an evaluation of the feasibility, safety, and short-term clinical effect of this approach. Central CIVDH is considered the contraindication for posterior PECD. A single-center retrospective observational study was performed with 30 patients managed with posterior PECD using the trench approach for symptomatic single-level central CIVDH. Primary outcomes included the measures of bodily pain and physical function based on the SF-36 and modified MacNab criteria. Radiographical follow-up included the static and dynamic cervical plain radiographs, computed tomographic scans, and magnetic resonance images. A positive clinical response for symptom relief was achieved in all patients. The postoperative MRI showed total removal of the herniated disc. As a supplement to the described surgical techniques of PECD, this trench approach provides novel access for the treatment of CIVDH, especially for the central type. The advantages of this technique include the provision of access to decompress the ventral region of the thecal sac and the ability to avoid damage to the facet joint. The steep learning curve might be a major disadvantage, and the sample volume is a limitation of the study; the effectiveness and reliability of the trench approach should be further verified in a comparative cohort study with a large volume of patients.

Clinical study of Bushen-Tongdu decoction combined with percutaneous minimally invasive surgery for the degenerative lumbar spinal stenosis

Objective To observe the curative effect of Bushen-Tongdu decoction combined with percutaneous minimally invasive decompression for degenerative lumbar spinal stenosis. Methods A total of 80 patients with degenerative lumbar spinal stenosis were selected and divided into two groups of 40 cases by random number table. The control group was treated with percutaneous transforaminal minimally invasive decompression. The treatment group was given Bushen-Tongdu decoction on the basis of the control group. Both groups were treated for 14 days. The Japanese orthopedic Society back pain evaluation criteria for waist pain, leg pain and numbness, walking ability, sensory dysfunction, dyskinesia, straight leg raising test score were collected and compared. Results The total effective rate was 95.00% (38/40) in the treatment group and 82.50% (33/40) in the control group. The total effective rate of the two groups was statistically significant (Z=-2.357, P=0.018). After treatment, the levels of waist pain score, leg pain and numbness score, walking ability score, sensory dysfunction score, dyskinesia score and the straight leg raising test score in the treatment group were significantly higher than those in the control group(t=-2.180, -2.059, -1.985, -2.177, -2.045, -2.238, P<0.05). Conclusions The Bushen-Tongdu decoction combined with percutaneous minimally invasive decompression can reduce pain, improve walking ability, improve sensory and motor dysfunction, and improve clinical efficacy of the patients with degenerative lumbar spinal stenosis. Key words: Spinal stenosis; Lumbar vertebrae; Conservative treatment; Bushen-Tongdu decoction; Decompression, surgical; Diskectomy, percutaneous

Endoscopic spine discectomy: indications and outcomes.

Percutaneous endoscopic discectomy is an effective minimally invasive spine surgery (MISS) for soft disc herniations. The objective of this review was to describe the current indications, surgical techniques, and clinical outcomes of endoscopic spine surgery. A narrative review was performed with a focus on surgical indication of percutaneous endoscopic discectomy and the clinical outcomes in lumbar and cervical spine. Percutaneous endoscopic or full-endoscopic discectomy using a working channel endoscope was described. The basic principles, surgical techniques, and clinical outcomes in lumbar and cervical disc herniations were demonstrated. For the lumbar disc herniation (LDH), transforaminal and interlaminar approaches were reviewed, whereas for the cervical disc herniation (CDH), anterior and posterior approaches were reviewed. Endoscopic spine surgery for soft disc herniation can be effective with benefits of minimal tissue trauma in properly selected cases. Given the recent technical advancements, the surgical indications for endoscopic spine surgery are still expanding and the clinical results have become more practical and reliable.

Minimally invasive discectomy for lumbar disc herniation: current concepts, surgical techniques, and outcomes.

To date, various minimally invasive surgeries for lumbar disc herniation (LDH) have been performed in many countries, including microendoscopic discectomy (MED) and percutaneous endoscopic discectomy (PED). We herein report the surgical indications, current concepts, and techniques of minimally invasive discectomy for LDH, including MED and PED. The postoperative outcomes and risks of complications compared with conventional discectomy are also discussed. By reviewing past literatures, the current concepts, surgical techniques, and clinical outcomes were described. Minimally invasive discectomy is generally performed using a transmuscular approach with an endoscopic technique and can reduce muscle and soft tissue damage. The minimal invasiveness can also reduce the severity of postoperative pain and improve patient satisfaction compared with conventional open discectomy. Based on the data of previous systematic reviews and meta-analyses, minimally invasive lumbar discectomy, such as MED and PED, appears to be safe and effective alternatives to open discectomy for patients with symptomatic LDH. These minimally invasive surgeries can provide beneficial effects to shorten the hospital stay and time to return to work. However, minimally invasive discectomy has a demanding learning curve. Only a well-trained surgeon and support team should perform these less invasive procedures. Clinical evidence supporting the superiority of MED and PED is still limited. Well-designed prospective multicentered randomized controlled trials with large samples are therefore needed in order to draw a convincing conclusion.

Percutaneous Endoscopic Lumbar Discectomy versus Conventional Open Discectomy: A Prospective Randomized Comparative Trial

Introduction: The majority of series considered the conventional open discectomy as the gold standard for the treatment of lumbar disc prolapse. Despite of the popularity of the lumbar endoscopic discectomy nowadays, many neurosurgeons still prefer conventional open discectomy. Purpose: Our study has been designed to compare between percutaneous endoscopic lumbar discectomy and conventional open discectomy; regarding surgical results, complications, clinical and functional outcomes. Patients and Methods: This study is a clinical prospective randomized controlled trial conducted upon 30 patients suffering from prolapsed lumbar disc, from December 2016 to May 2018. Those patients were divided randomly into 2 groups, 15 patients each. One group treated by percutaneous endoscopic interlaminar lumbar discectomy (PELD) and the other group treated by conventional open discectomy (COD). Operative time, wound size, Intraoperative blood loss, Intraoperative complications, postoperative hospital stay, Postoperative complication and the results of visual analogue score (VAS) and modified MacNab’s criteria were assessed. Results: This study included 30 patients (18 males and 12 females). The mean age was about 35 years. Although, there was postoperative improvement of the VAS and MacNab’s criteria in the two groups, there was no statistically significant difference between the preoperative and postoperative VAS of low back pain and radicular pain for the two groups in the follow up period. Conclusion: Both techniques give good results for patients; each technique has some advantages over the other.

A comparative study on short-term therapeutic effects of percutaneous transforaminal endoscopic discectomy and microendoscopic discectomy on lumbar disc herniation.

Objective:To find out the short-term effects of percutaneous transforaminal endoscopic discectomy (PTED) and microendoscopic discectomy (MED) on lumbar disc herniation (LDH).Methods:Ninety LDH patients treated in PLA Army General Hospital from July 2015 to July 2016 were selected and randomly divided into an MED group and a PTED group. Length of incision, amount of intraoperative bleeding, surgical time, number of times using intraoperative fluoroscopy, postoperative bedridden time, hospital stay, together with visual analogue scale (VAS) and Oswestry disability index (ODI) scores before surgery, three days, three months and six months after surgery were analyzed.Results:As regards the length of surgical incision, amount of bleeding, postoperative bedridden time and hospital stay, the PTED group was significantly superior to the MED group ((P=0.000, 0.000, 0.000, 0.001, respectively)). Compared with the PTED group, the MED group used less fluoroscopy and had shorter surgical time (P=0.001, 0.000, respectively). The postoperative VAS and ODI scores of both groups were significantly improved compared with those before surgery (P<0.000, 0.000, respectively). The short-term postoperative low back pain (LBP) VAS score of PTED group was lower than that of MED group (P=0.001). The two groups had similar leg pain (LP) VAS score three and six months after surgery, postoperative and follow-up LP VAS and ODI scores, and surgical improvement rate (P=0.093, 0.097, respectively).Conclusion:LDH was effectively treated by both PTED and MED. Compared with MED, PTED had less trauma, less blood loss, and faster recovery after surgery.

Thermal Annuloplasty Using Percutaneous Endoscopic Discectomy for Elite Athletes with Discogenic Low Back Pain.

The purpose of this study was to assess the usefulness of radiofrequency thermal annuloplasty (TA) using percutaneous endoscopic discectomy/TA (PED/TA) in elite athletes with discogenic low back pain. Twelve patients (11 men, 1 woman; mean age 27.9 years) underwent PED/TA under local anesthesia. Clinical data for these patients (17 affected intervertebral discs), including type of sport played, average duration of low back pain, disc level affected, presence or absence of a high signal intensity zone on magnetic resonance imaging, and whether the patient returned to playing competitive sport, were retrospectively reviewed. The most common sport played by the patient was baseball (n = 8), followed by cycling (n = 2), tennis (n = 1), and hammer throw (n = 1). The average duration of low back pain was 24.3 months. The intervertebral disc levels affected were L4/5 (n = 11) and L5/S1 (n = 6). A high signal intensity zone was detected in nine discs. Although two patients required additional surgery, all patients were able to return to their original competitive level of play. Duration for the return to play was 2.8 months after surgery except the two revision cases. PED/TA for discogenic pain enables an early return to competitive sports, and so is particularly useful for elite athletes.