Procedure For Lumbar Disc Herniation Research Articles

Hidden blood loss in three different endoscopic spinal procedures for lumbar disc herniation

Purpose: This study compared hidden blood loss (HBL) among three different endoscopic spinal procedures and investigated its risk factors. Patients and methods: This single-centre retrospective analysis collected data from consecutive hospitalized patients with single-segment lumbar disc herniation (LDH) undergoing unilateral biportal endoscopic discectomy (UBE), percutaneous endoscopic transforaminal discectomy (PETD), or percutaneous endoscopic interlaminar discectomy (PEID) from December 2020 to October 2022. HBL was calculated using Nadler’s and Gross’s formulas. The authors used Pearson’s or Spearman’s correlation analysis to explore the relationship between patient characteristics and HBL. Multivariate linear regression analysis was used to identify independent risk factors for HBL. Results: In total, 122 consecutive patients (68 females and 54 males) were enroled in this study. The average HBL was 381.87±218.01 ml in the UBE group, 252.05±118.44 ml in the PETD group and 229.63±143.9 ml in the PEID group (P<0.05). Pearson’s or Spearman’s correlation analysis showed that operative time, preoperative haemoglobin, preoperative haematocrit, and preoperative Albumin (ALB) were correlated with HBL in the UBE group, while sex, age, operative time, postoperative ALB, and patients’ blood volume (PBV) were related to HBL in the PETD group (P<0.05). Operative time and preoperative activated partial thromboplastin time were related to HBL in the PEID group (P<0.05). Multiple linear regression analysis showed a positive correlation between HBL and operative time in all three groups (P<0.001, P<0.001, P<0.05). Conclusion: HBL was higher in the UBE group than in the PETD and PEID groups, and operative time may be a common risk factor for the three groups.

Comparison of percutaneous endoscopic lumbar discectomy vs. minimally invasive transforaminal lumbar interbody fusion for the treatment of single-segment lumbar disc herniation: a meta-analysis.

Percutaneous endoscopic lumbar discectomy (PELD) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) have been commonly demonstrated as two effective choices for the treatment of lumbar disc herniation (LDH). This meta-analysis aims to compare the effects of PELD and MIS-TLIF for the treatment of single-segment LDH. Randomized controlled trials or prospective cohort studies published from the time when databases were built to January 2022 that compared the effects of PELD and MIS-TLIF for single-segment LDH were retrieved from a comprehensive search in six electronic databases (PubMed, Web of Science, Embase databases, Cochrane Library, Google Scholar, and CNKI). All analyses were performed with RevMan 5.4 software. A total of 9 studies with 1274 patients were included in this meta-analysis. The results showed that the PELD group was associated with lower visual analog scales (VAS) score for back pain at the final follow-up (MD: 1.23; 95% CI: [0.32, 2.14], p=0.008), higher Japanese Orthopaedic Association (JOA) score (MD: 2.29; 95% CI: [1.38, 3.19], p<0.00001), lower Oswestry Disability Index (ODI) score (MD: -2.46; 95% CI: [-4.50, -0.43], p=0.02), shorter operation time at 3 months (MD: -51.77; 95% CI: [-74.63, -28.91], p<0.00001) and lesser hospital stay (MD: -5.18; 95% CI: [-6.65, -3.71], p<0.00001), and less blood loss (MD: -187.13; 95% CI: [-281.45, -92.81], p=0.0001). However, it was associated with a higher rate of recurrent disc herniation (RR: 17.66; 95% CI: [4.25,73.44], p<0.0001). There were no significant differences between PELD and MIS-TLIF in VAS leg pain (MD: 0.12; 95% CI: [-0.24, 0.49], p=0.51), and complication rate (RR: 0.71; 95% CI: [0.45, 1.12], p=0.14). The existing evidence showed that PELD had significantly better outcomes than MIS-TLIF in JOA score at six months, operation time, blood loss, and hospital stay as a procedure for LDH, but it had a higher recurrence rate than MIS-TLIF. Meanwhile, we should have a good command of the pros and cons of the two surgical methods to formulate an appropriate surgical plan for the patients.

Risk Factors and Surgical Management of Recurrent Herniation after Full-Endoscopic Lumbar Discectomy Using Interlaminar Approach.

Full-endoscopic lumbar discectomy (FED) is one of the least invasive procedures for lumbar disc herniation. Patients who receive FED for lumbar disc herniation may develop recurrent herniation at a frequency similar to conventional procedures. Reoperation and risk factors of recurrent lumbar disc herniation were investigated among 909 patients who received FED using an interlaminar approach (FED-IL). Sixty-five of the 909 patients received reoperation for recurrent herniation. Disc height, smoking, diabetes mellitus (DM), subligamentous extrusion (SE) type, and Modic change were identified as the risk factors for recurrence. Other indicators such as LL, Cobb angle, disc migration, age, sex, and body mass index (BMI) did not reach significance. Among 65 patients, reoperation was performed within 14 days following FED-IL (very early) in 7 patients, from 15 days to 3 months (early) in 14 patients, from 3 months to 1 year (midterm) in 17 patients, and after more than 1 year (late) in 27 patients. The very early group included a greater number of males, and the mean age was significantly lower in comparison to other groups. All patients in the very early group received FED-IL for reoperation. Reoperation within 2 weeks allows FED-IL to be performed without adhesion. Fusion surgery was performed on three cases in the early and midterm groups and on 10 cases in the late group, which increased over time as degenerative change and adhesion progressed. The procedure selected to treat recurrent herniation mostly depends on the surgeon’s preference. Revision FED-IL is the first choice for recurrent herniation in terms of minimizing surgical burden, whereas fusion surgery offers the advantage that discectomy can be performed through unscarred tissues. FED-IL is recommended for recurrent herniation within 2 weeks before adhesion progresses.

Biportal endoscopic discectomy for high-grade migrated lumbar disc herniation.

Although endoscopic procedures for lumbar disc herniation have improved greatly and offer many advantages, the indications are limited mostly to nonmigrated or low-grade migrated disc herniation. Endoscopic application in migrated disc herniation cases is still challenging and technically demanding. The goal in this study was to determine the feasibility of biportal endoscopic discectomy for removal of high-grade migrated disc herniation. A retrospective review was performed in 262 patients who had undergone biportal endoscopic discectomy after the diagnosis of lumbar herniated disc. According to preoperative MRI findings, disc herniation was classified into 5 zones based on the direction and distance from the disc space. Patients were divided into 2 groups-a high-grade migration group and a low-grade migration group. Clinical outcomes were evaluated using the Oswestry Disability Index (ODI), visual analog scale (VAS), and modified Macnab criteria, and those outcomes and operation time were compared between the 2 groups. There were 10 patients with "high-grade up," 8 with "low-grade up," 98 with disc-level, 102 with "low-grade down," and 44 with "high-grade down" herniation, thereby yielding 54 patients in the high-grade group and 208 in the low-grade group. Demographic data for the 2 groups showed no significant difference. There was no significant difference between the 2 groups in ODI, VAS, and modified Macnab criteria. Operation time between the 2 groups was not significantly different (60.74 vs 65.63 minutes, p > 0.05). Biportal endoscopic discectomy can be effective for high-grade migrated lumbar disc herniation with no prolonged operation time and satisfactory clinical outcomes.

Transforaminal percutaneous endoscopic discectomy for lumbar disc herniation in athletes under the local anesthesia

BackgroundPercutaneous endoscopic discectomy (PED) has been reported to be less invasive and effective procedure for lumbar disc herniation (LDH). Damage to the back muscle is considered minimal, which is particularly important for athletes. However, the results of PED for LDH in athletes have not been reported well. The purpose of this study was to evaluate the clinical outcomes of PED for LDH in athletes. MethodsWe retrospectively analyzed 21 athlete patients with LDH who had undergone PED. All patients received athletic rehabilitation immediately after surgery. The clinical outcomes were evaluated from the visual analogue scale (VAS) for leg pain and low back pain (LBP), the Oswestry Disability Index (ODI), complications and periods of return to sport. ResultsThere were 18 men and 3 women, and the mean age at the time of surgery was 22.9 years (range: 15–43 years). The mean VAS scores for leg pain before and after surgery were 64.3 ± 2.7 mm and 12.4 ± 1.4 mm, respectively. The mean VAS scores for LBP before and after surgery were 62.1 ± 2.2 mm and 10.5 ± 1.1 mm, respectively. The mean ODI scores before and after surgery were 31.3 ± 14.0% and 14.6 ± 7.1%, respectively. The VAS for leg pain, as well as the LBP and ODI, significantly improved after surgery. There were no complications related to the surgery. Ninety-five percent (20/21) returned to play sports at the same performance level as before the procedure by an average of 9.2 weeks after PED. ConclusionsPED is a minimally invasive and effective procedure for patients with LDH, especially in athletes. Not only the patients' leg pain but also their discogenic LBP improved. PED has the benefits of preservation of normal posterior structures and a faster return to sports.

Operative Management of Lumbar Disc Herniation with End Plate Modic Changes Necessitates More Definite Procedures

Introduction Nucleotomy through interlaminar fenestration has been the standard operation for lumbar disc herniation, but it does not always work well in clinical practice. End plate Modic changes are strongly linked with lower back pain, and Modic changes in the end plates of the herniation level may be one reason for the unpredictable result of nucleotomy alone. Studies on more definite surgical procedures for lumbar disc herniation with end plate Modic changes are still rare. To compare the clinical outcomes between two surgical options, nucleotomy alone and nucleotomy with additional posterolateral lumbar interbody fusion (PLIF), for lumbar disc herniation patients with end plate Modic changes, and to testify the hypothesis that end plate Modic change is an indication of interbody fusion for operative management of lumbar disc herniation. Materials and Methods A total of 91 patients who complained about both lower extremity radicular pain and lower back pain (lower back pain more severe than leg pain) were included, and all of them were of single segment disc herniation with Modic changes in the corresponding lumbar degenerative end plates. Of the 91 patients, 47 were treated with nucleotomy alone and 44 were treated with posterolateral lumbar interbody fusion (PLIF) in addition to nucleotomy. They were followed up for at least 2 years. Clinical outcomes were evaluated according to the Japanese Orthopaedic Association (JOA) score and visual analogue scale (VAS) for lower back pain and VAS for lower extremity radicular pain before operation and at each follow-up, and the results before surgery and at 18 months after operation were statistically compared. Results In both the groups, the JOA scores, as well as VAS, for lower back pain significantly improved 18 months after surgery. The improvement rate of JOA score and power of improvement of VAS for lower back pain also showed significant difference between the two groups, being better in nucleotomy with PLIF procedure than in nucleotomy alone procedure. On the contrary, the mean VAS of lower extremity radicular pain showed a significant reduction in both groups at the follow-up of 18 months after operation. However, a significant difference of the power of this improvement between both the groups was not found. Conclusion Operative management of lumbar disc herniation with end plate Modic changes necessitates more definite procedures in addition to nucleotomy. PLIF is a good and reliable option. Disclosure of Interest None declared

Comparison of Surgical Outcomes Between Macro Discectomy and Micro Discectomy for Lumbar Disc Herniation: A Prospective Randomized Study With Surgery Performed by the Same Spine Surgeon

A prospective study was conducted on the surgical procedures for lumbar disc herniation. The objective of this study is to investigate the surgical outcomes of different methods when performed by the same surgeon, using a prospective study. Macro discectomy is widely known as a common surgical procedure for lumbar disc herniation, while microdiscectomy in place of Caspar technique (the Caspar method) and microendoscopic discectomy by a posterior approach are reported as less invasive surgical methods for this condition. However, there have not been a significant number of prospective studies conducted to compare different surgical procedures for lumbar disc herniation. The target of our study was a group of 62 patients (male: 43, female: 19) who underwent surgery by macro discectomy (A group) and 57 patients (male: 33, female: 24) who underwent surgery by microdiscectomy in place of Caspar technique (B group). The mean ages at surgery were 34 (14 to 62) years and 41 (18 to 65) years respectively, and the mean duration of follow-up was 2 years and 8 months (12 months to 4 years). For all patients, the surgery was performed by 1 of the authors. The items investigated were the operation time, amount of bleeding, duration of hospitalization, amount of analgesic agent used after surgery, pre- and postoperative scores based on judgment criteria for treatment of lumbar spine disorders established by the Japanese Orthopaedic Association score, visual analog scales (VAS, 0 to 10) for lumbago before surgery and at discharge, VAS for sciatica before surgery and at discharge, perioperative complications, and cases requiring further surgery. There were no significant differences between the 2 surgical procedures in the frequency of use of an analgesic agent after surgery, the pre- and postoperative Japanese Orthopaedic Association scores or postoperative VAS for sciatica. Statistically significant differences were observed in the operation time, amount of bleeding, duration of hospitalization, and postoperative VAS for lumbar pain, but the differences were not large, and may not have been clinically significant. For herniotomy for lumbar disc herniation, both macro discectomy and microdiscectomy are appropriate, as long as surgeons have mastery of the procedures.

Percutaneous Endoscopic Interlaminar Discectomy for Intracanalicular Disc Herniations At L5–S1 Using a Rigid Working Channel Endoscope

Percutaneous endoscopic transforaminal discectomy is often used as a minimally invasive procedure for lumbar disc herniation. However, a transforaminal approach posts limitations at the L5-S1 level owing to anatomic constraints, such as a high iliac crest or small intervertebral foramen and especially for migrated large intracanalicular disc herniations. We discuss the procedure and clinical results of percutaneous endoscopic interlaminar discectomy using a rigid working channel endoscope at the L5-S1 level and the relevant surgical anatomy. We performed percutaneous endoscopic discectomy through the interlaminar approach in 67 patients who satisfied our inclusion criteria during the period from March 2002 to November 2002. All procedures were performed under local anesthesia. Under fluoroscopic guidance, we performed discography using indigocarmine mixed with radio-opaque dye. The 6-mm working channel endoscope was then introduced into the epidural space. Herniated disc material was removed using forceps and laser under clear endoscopic visualization. We retrospectively evaluated the 65 cases with more than 1.5 years of follow-up. The patients were evaluated using the visual analogue scale (VAS) and the Oswestry Disability Index (ODI). VAS for leg pain (preoperative mean, 7.89; postoperative mean, 1.58) and ODI (preoperative mean, 57.43; postoperative mean, 11.52) showed statistically significant (P = 0.00) improvement in their values at the last follow-up examination compared with preoperative scores. Of the study group, 90.8% individuals showed favorable result. The mean hospital stay was 12 hours. The average time to return to work was 6.79 weeks. Complications included two cases of dural injury with cerebrospinal fluid leakage, nine cases of dysesthesia that were transient, and one case of recurrence. Two patients required conversion to open procedure at the initial operation. There was no evidence of infection in any patients. Percutaneous endoscopic interlaminar discectomy is a safe, effective, and minimally invasive procedure for the treatment of intracanalicular disc herniations at the L5-S1 level in properly selected cases, especially when the transforaminal approach is not possible because of anatomic constraints.

Microendoscopic discectomy (MED) for lumbar disc prolapse

Microendoscopic discectomy (MED), which combines traditional lumbar microsurgical techniques with endoscopy, is being used as a minimally invasive procedure for lumbar disc herniation. We reviewed 30 patients who underwent MED at our institution and compared their outcome with that of patients subjected to the conventional method. Laboratory data suggested that MED was less invasive surgery. Moreover, MED allowed an early return to work. However, the difficulties of this endoscopic procedure were evident, because of the limited exposure and two-dimensional video display. The potential injury of the nerve root and prolonged surgical time remain as matters of serious concern. To overcome this problem, we used an operative magnifying glass during surgery and this helped us to accomplish the procedure comfortably. We recommend the use of an operative magnifying glass in the early stage of the introduction of MED, for it is quite useful to identify the three-dimensional relationships of the structures.

Postoperative Magnetic Resonance Imaging of Lumbar Disc Herniation

We performed a study to compare the magnetic resonance imaging findings up to 24 weeks after microendoscopic discectomy or surgery using Love's method in patients with lumbar disc herniation. The objective was to determine whether or not microendoscopic discectomy was minimally invasive with respect to the nerve roots, cauda equina, and paravertebral muscles by comparing the postoperative magnetic resonance imaging findings in patients treated by microendoscopic discectomy and the conventional Love's method. We introduced microendoscopic discectomy as a minimally invasive surgical procedure for lumbar disc herniation in September 1998 and have obtained good results. Microendoscopic discectomy is superior to the conventional Love's method in that it reduces postoperative pain, shortens the duration of hospitalization, and allows earlier resumption of normal activities. However, the effect of microendoscopic discectomy on the nerves and paravertebral muscles has not been evaluated objectively. Enhancement of the nerve roots and paravertebral muscles, as well as the configuration of the cauda equina at the level of herniation, was assessed on axial magnetic resonance images obtained with contrast enhancement using gadolinium-diethylenetriamine penta-acetic acid before surgery and 1, 4, 8, 12, and 24 weeks after surgery in 25 patients who underwent microendoscopic discectomy and 15 patients who were treated using Love's method. Increased enhancement of the nerve roots was seen in 50.0% of the microendoscopic discectomy group and 46.2% of the Love group at 1 week after surgery. Enhancement of the paravertebral muscles at the surgical site tended to persist for longer in the microendoscopic discectomy group than in the Love group. However, muscle enhancement was widespread in some patients from the Love group. Abnormalities of the cauda equina attributed to surgical invasion were seen in 12.5% of the microscopic discectomy group and 15.4% of the Love group at 1 week after surgery. Microendoscopic discectomy had an effect on the nerve roots and cauda equina that was comparable with that of Love's method. The magnetic resonance images of the route of entry failed to show that microendoscopic discectomy is appreciably less invasive with respect to the paravertebral muscles.

Ten- to 15-year outcome of surgery for lumbar disc herniation: radiographic instability and clinical findings.

The most appropriate treatment for radiculopathy associated with disc pathology is still controversial. Since 1934, surgical treatment has consisted of hemilaminectomy and removal of the herniated material. Many authors believe that these procedures may cause degenerative spondylosis and vertebral instability. Several surgical methods have been proposed, but the long-term effects are still being debated. In addition there appear to be few well-designed outcome studies on the management of this disease. In the present study, 150 patients were selected for surgery with strict criteria and all treated with the standard technique. The series was evaluated by subjective analyses (Roland questionnaire; 120 patients), objective examinations (68 patients - 56.6%) and radiographic studies including dynamic views (analyzed by the Taillard and Boxall methods) to establish the presence of vertebral instability (50 patients - 41.6%). The subjective and objective analyses showed a high rate of good results. Radiographic studies showed vertebral instability in 30 cases, but only 9 were symptomatic. Recurrences were not observed and only a few patients suffered from leg pain. The standard procedure for lumbar disc herniation showed good results at 10- and 15-year follow-up.

Lumbar Disc Surgery in a Fixed Compensation Population: A Model for Influence of Secondary Gain on Surgical Outcome

Background Reported outcomes in patients undergoing surgical procedures for lumbar disc herniation are poorer in patients eligible for workers’ compensation or with pending litigation. In the civilian community, the amount of compensation for one’s disability is variable and thus its influence on surgical outcome is difficult to quantify. In the military, all members are covered by a standardized workers’ compensation system, and have generally standardized work requirements, a standard pay scale, and third party evaluation of disability based on the Veterans Affairs rating system. This made the military a good system in which to study the effect of potential compensation on surgical outcome. Methods The study population consisted of active duty military members who underwent sequential lumbar microdiscectomies over a 31-month period. Omitted were lumbar fusions, decompressive laminectomies, and far lateral discectomies. Clinical and demographic variables, along with financial data for each patient were derived from these data. A good result was defined as return to active military duty. Results Three hundred forty-nine lumbar discectomies were performed in 348 active duty military members. Overall, 75.3% (262) of the 348 patients were able to return to full military duty after surgery, and 24.7% (86) received disability compensation. Chi-square univariate analysis showed higher compensation incentive was a significant determinant of poor surgical outcome (p = 0.0021). The influence of compensation incentive was proportional to the amount of anticipated payout, and relative to a military service member’s usual income. In multivariate analysis, lower base pay (0.0005) and female gender (p = 0.038) were predictive of poor outcome. Conclusions Secondary gain in the form of disability pay has a proportionally adverse effect on outcome following lumbar disc surgery. Although studying this issue in the military system allowed standardization of secondary gain values, the influence of other factors could not be eliminated entirely. Potential disability pay is proportionally greater in lower ranked service members. Thus, other variables such as income level, education, and job satisfaction may contribute to the poorer results in this subgroup of military members.

腰椎椎間板ヘルニアに対する経皮的レーザー椎間板切除術

Percutaneous laser discectomy (PLD) is a safe, simple and minimally invasive procedure for lumbar disc herniation. Early therapeutic results were evaluated for 10 patients with lumbar disc herniation treated by PLD. The improvement rate of PLD according to JOA scroe was more than 75% in 3 patients, 74 to 50% in 5 and less than 49% in 2 at least 3 months after PLD, giving an overall success rate of 80%. There was no significant difference in clinical data and total irradiated energy between successful (8 patients) and unsuccessful (2 patients) groups. However, the age of 3 patients who obtained excellent results was under 40 years old.

前方髄核摘出術よりみた径皮的髄核摘出術の位置付け，他術式との比較検討

We have experienced 2201 cases surgically treated for lumbar disc herniation from 1976 to 1993. Treatments included 22cases of anterior nucleotomy (AN), 29 with anterior discectomy (AD) and 38 cases of percutaneous nucleotomy (PN) from 1986. Of these 18 cases of AN, 25 of AD and 36 of PN were clinically evaluated using the JOA score.The post-operative results were as follows:Average improvement rate was 77.8%, 72.7% and 55.6% in AN, AD and PN respectively. Excellent and good rates were 89%, 88% and 69%. A satisfactory rate was achieved in 83%, 76% and 72% of patients respectively.Postoperative merits were in order of AN, AD and PN. As a rule AN and AD are considered extensive major surgery due to the abdominal incision and general anesthesia, but the average operation time is 20 minutes and duration of return to former professional activities (sport and job) is with in 3 to 6 weeks. Therefore AN and AD are better procedures for lumbar disc herniation than PN.On the other hand there are many reports that the results of PN are not so satisfactory, therefore the indication must be discreet and not extensive. We have indicated cases with higher intradiscal pressure and less disc degeneration because of the need for intradiscal decompression.The best indication is intradiscal herniation. Furthermore many authors report that the technique is an intermediate procedure between surgery and conservative treatment, but PN is almost the same as surgical treatmert due to its disc damage and accidental complications.