Transforaminal Endoscopic Discectomy Research Articles

OP06 Percutaneous Transforaminal Endoscopic Discectomy: From Insufficient Evidence To Reimbursement

IntroductionThe standard surgical technique for lumbosacral radicular syndrome in the Netherlands is open microdiscectomy (OM). An alternative technique, preferred by some Dutch physicians, is percutaneous transforaminal endoscopic discectomy (PTED). However, in 2006 the Dutch National Health Care Institute (Zorginstituut Netherland [ZIN]) concluded that the available evidence was insufficient, and a high quality randomized controlled trial (RCT) was needed to assess the cost-effectiveness of PTED compared to OM. The relevant physician group agreed with this conclusion, but they were unable to perform this RCT due to lack of funding and high treatment costs.MethodsIn 2012, the Netherlands introduced a conditional reimbursement (CR) program to give patients earlier access to promising treatments. Researchers, in collaboration with physicians and patients, submitted a grant proposal and in 2016 the Dutch Ministry of Health approved the CR of PTED. Due to this decision, insurance companies were obliged to reimburse PTED for patients participating in the PTED-study (NCT02602093). The Netherlands Organization for Health Research and Development (ZonMw) also provided a research grant to fund the PTED-study. In total, 682 adult patients with greater than 10 weeks of radiating pain, or greater than 6 weeks of excessive radiating pain and an indication for surgery were included. After 4 years and 5 months the PTED-study was completed.ResultsOutcomes of published studies and the unpublished PTED-study were used in the HTA reassessment. Results showed that PTED was noninferior to OM with regards to leg pain (Visual Analogue Scale: mean difference (MD) -0.73; 95% confidence interval [CI] -5.04, 3.59), functional status (Oswestry Disability Index: MD -2.07; 95% CI -3.61, -0.53), and rate of complications (relative risk 0.45; 95% CI 0.18, 1.12) after 6 months (GRADE level ‘moderate’). Furthermore PTED was, after the surgeons’ learning-curve, cost-effective.ConclusionsThis CR project was successful and PTED is now reimbursed as part of the Dutch healthcare package. However, in order to maintain high quality care in clinical practice, safeguards should be developed (including the appropriate training of surgeons). This example shows that CR programs are essential for promising treatments without ‘wealthy’ manufacturers. Additionally, all stakeholders are needed to make a CR-study successful.

Assessment of Spinal Stability after Discectomy Followed by Annulus Fibrosus Repair and Augmentation of the Nucleus Pulposus: A Finite Element Study

Lumbar disc herniation (LDH) is a common condition which can lead to back pain. Although surgical treatments for LDH are well established, complications such as spinal instability and narrowing of adjacent facet joints are still frequently reported. The purpose of this study was to use finite element models to evaluate the stability of the L3–L4 segment after conservative or aggressive percutaneous transforaminal endoscopic discectomy (PTED) with and without an artificial material filler to correct LDH. Compared to the intact model, aggressive PTED reduced the stability of the segment (increased ROM) and narrowed the space between facet joints in the medial/lateral (ML) direction during flexion (maximum 6.7 degrees change in ROM and 90.5% spacing between facet joints), extension (maximum 2.1 degrees and 38.6%), and axial rotation (maximum 4.2 degrees and 90.1%). Aggressive PTED had a similar effect in the anterior/posterior (AP) direction during lateral bending (maximum 2.0 degrees and 44.2%). Augmenting the nucleus pulposus with a polyurethane filler after aggressive PTED improved spinal stability in both the ML and AP directions in all simulated motions, with results similar to the intact model. However, using a hydrogel filler did little to stabilize the spine, likely because the material is too soft to support the heavy, sustained loading. In conclusion, this study found that if an aggressive discectomy is required, augmenting the nucleus pulposus with a PU filler provides sufficient support to stabilize the spine, while hydrogel fillers offer little support.

Comparison of percutaneous transforaminal endoscopic discectomy and open lumbar discectomy for lumbar disc herniations: A systematic review and meta-analysis.

In order to compare the outcomes of percutaneous transforaminal endoscopic discectomy (PTED) and open lumbar discectomy (OLD) for lumbar disc herniation (LDH). The Pubmed, Cochrane Library, Web of Sience, Embase, Clinicaltrials.gov, CBM, CNKI, VIP, Wangfang databases were searched from inception to April 30, 2022 to collect the published studies about PTED vs. OLD for treatment of LDH. The Revman 5.2 was used for data analysis. The primary outcomes were excellent rates, complication rates and reoperation rates. The secondary outcomes were length of incision, length of operation, length of hospital stay, and the amount of intraoperative blood loss. A total of nine studies were included, of which, eight randomized controlled trials and one retrospective study involving 1,679 patients with LDH (755 patients for PTED, and 924 patients for OLD) were included. According to meta-analysis, there were no significant difference in excellent rates (odds ratio [OR] = 1.47, 95% confidence intervals [CI]: 0.94-2.28, P = 0.09), reoperation rates (OR = 0.96, 95% CI: 0.50-1.84, P = 0.90), length of operation [standardized mean differences (SMD) = -17.97, 95%CI: -54.83-18.89, P = 0.34], and the amount of intraoperative blood loss (SMD = -128.05, 95%CI: -258.67-2.57, P = 0.05), respectively. There were significant differences in complication rates (OR = 0.22, 95% CI: 0.14-0.33, P < 0.001), length of incision (SMD = -2.76, 95%CI: -2.88--2.65, P < 0.001), and length of hospital stay (SMD = -5.19, 95%CI: -5.36--5.01, P < 0.001), respectively. PTED can achieve better outcomes with respect to the complication rates, length of incision, and length of hospital stay compared with OLD.

Effect of intradiscal local anesthetic injection on intraoperative pain during percutaneous transforaminal endoscopic discectomy: A retrospective study

ObjectivePatients undergoing percutaneous transforaminal endoscopic discectomy (PTED) often complain of unbearable intraoperative pain. This study is to observe clinical effectiveness and safety of intradiscal local anesthetic injection for intraoperative pain relief. MethodsTotal 268 patients who underwent PTED were analyzed. Patients were divided into intradiscal saline injection group (group C) and intradiscal local anesthetic injection group (group L). Intradiscal mixture was consisted of saline or local anesthetic + methylene blue, the amount of injected mixture was 3 mL. Demographic data, visual analog scale (VAS) and Quebec Back Pain Disability Scale (QBPDS) scores, mean arterial pressure (MAP) and heart rate (HR), total dosage of fentanyl, satisfaction rate of anesthesia and complications were collected at different timepoints. ResultsCompared with group C (3.94 ± 0.57), there was a significant reduction of VAS in group L (2.83 ± 0.28) during fibrous annular operation phase (T2). Group L had a lower total dosage of fentanyl (71 [63, 78] μg) and a higher anesthesia satisfaction rate (95.3%) than group C (82 [70, 132] μg and 73.6%, respectively) (P < 0.001). MAP and HR were lower in group L than in group C at T2 (P < 0.001). Baseline characteristics and QBPDS scores showed no meaningful intergroup differences. Four cases of complications were reported in this study. ConclusionIntradiscal local anesthetic injection significantly alleviated intraoperative back pain and increased the satisfaction rate of anesthesia, without severe complications, indicating that this technique is a feasible method for intraoperative back pain relief for patients undergoing PTED.

MRI changes of adjacent segments after transforaminal lumbar interbody fusion (TLIF) and foraminal endoscopy: A case-control study.

Background:Intervertebral foramen endoscopy has developed rapidly, but compared with transforaminal lumbar interbody fusion (TLIF), the progress of degeneration is unknown. We aim to compare the changes of intervertebral disc and intervertebral foramen in adjacent segments after TLIF and endoscopic discectomy for patients with lumbar disc herniation (LDH).Methods:From 2014 to 2017, 87 patients who were diagnosed with single-level LDH and received surgery of TLIF (group T, n = 43) or endoscopic discectomy (group F, n = 44) were retrospectively analyzed. X-ray, MRI, CT and clinical symptoms were recorded before operation and at the last follow-up (FU). The neurological function was originally evaluated by the Japanese Orthopaedic Association (JOA) scores. Radiological evaluation included the height of intervertebral space (HIS), intervertebral foramen height (FH), intervertebral foramen area (FA), lumbar lordosis (CA) and intervertebral disc degeneration Pfirrmann scores.Results:There was no significant difference in baseline characteristics, JOA improvement rate, reoperation rate and complications between the two groups. The age, average blood loss, average hospital stays and average operation time in group F were lower than those in group T. During the last FU, HIS, CA and FA decreased in both groups, and the changes in group T were more significant than those in group F (P < .05). There was no significant difference in FH changes between the two groups (P > .05).Conclusion:Both TLIF and endoscopic surgery can achieve good results in the treatment of LDH, but the risk of lumbar disc height loss and intervertebral foramina reduction in the adjacent segment after endoscopic surgery is lower.

Endoscopic lumbar discectomy vs microdiscectomy: Early results, complications and learning curve an Australian perspective

BackgroundEndoscopic spine surgery has been recently introduced in Australia. A comparison of endoscopic lumbar discectomy, open or microscopic approach with learning curve is presented. Patients and methodsA retrospective observational cohort study design of Uniportal endoscopic lumbar discectomy of a single surgeon series was conducted. All patients above 18 years of age with symptomatic disc herniation and who have failed non-surgical management were selected. This data is the initial 30 consecutive uniportal endoscopic lumbar discectomy patients (group E). These were compared to the immediately prior 30 lumbar microdiscectomy (Group M) cases of the same surgeon. Demography, operative data, complications and postoperative results were collected. Learning curve duration for endoscopic cases was also examined. ResultsThere were 39 males and 21 females with mean age of 53.6 yrs. In group E there were 23 Transforaminal cases and 7 interlaminar cases. Mean operative time was 125.5 min. The first 10 cases took 181 mins, next 111mins and last 10, 84 mins showing a vast improvement with learning curve. A significant difference in operative time between transforaminal endoscopic and interlaminar endoscopic discectomy (P < 0.001) was found. On comparison of endoscopic and microscopic cases a significant difference was found in blood loss (p < 0.001) and there was an expected non-significant difference in operation time. Complication rates at 6 weeks were comparable (dural tears – 1 E, 2 M) and recurrent discs (E = 1,M = 2). An additional recurrence occurred at 20 weeks postop in the endoscopic group that required a revision discectomy surgery. ConclusionWe present an Australian perspective of endoscopic vs microscopic lumbar discectomy. Early results reveal comparable outcomes of endoscopic lumbar discectomy compared to microscopic surgery with respect to operative time, blood loss and complications. In endoscopic cases, interlaminar approach had longer operative time and complications compared to transforaminal approach. With the learning curve the operative times improved. Further studies are required to evaluate long term outcomes and complications.

Transforaminal endoscopic lumbar discectomy with targeted puncture and foraminotomy for very highly migrated disc herniation: A technique note with case series

BackgroundTransforaminal endoscopic lumbar discectomy (TELD) has been widely used for lumbar disc herniation. However, in some challenging cases such as very highly migrated disc herniation (VHMDH), traditional TELD is difficult to access the pathology. MethodsFrom January 2016 to December 2019, 63 patients with single-level VHMDH underwent TELD using targeted puncture and foraminotomy techniques were included. All patients were followed up for 26.5 months on average (range, 24–48 months). Operative time, length of hospital stay, visual analog scale (VAS) score, Oswestry Disability Index (ODI), modified MacNab criteria and surgical complications were evaluated. ResultsThe operative time was 40–120 min (56.8 on average). The length of hospitalization was 2.5 days (range, 2–4 d). VAS score decreased significantly from 5.5 ± 1.3 preoperatively to 1.9 ± 1.30 (p < 0.001) 1 day postoperatively, and to 0.9 ± 0.8 (p < 0.001) at the final follow-up. ODI score improved significantly from 23.5 ± 3.2 preoperatively to 13.4 ± 3.0 (p < 0.001) 1 day postoperatively; and 3.1 ± 1.2 (p < 0.001) at the final follow-up. According to the modified MacNab criteria, 40 patients (63.5%) showed excellent results, 20 patients (31.7%) were rated as good, 2 patients (3.2%) were rated as fine, and 1 patient (1.6%) was rated as bad at the final follow-up. No residual fragments, nerve root or cauda equina injury was shown in this series. One recurrent case was resolved by open surgery. ConclusionsWith modified targeted puncture and foraminotomy techniques, VHMDH can be accessed safely and effectively, and satisfactory clinical outcomes can be obtained for these patients.

Comparative Analysis of Transforaminal Endoscopic Thoracic Discectomy and Microscopic Discectomy for Symptomatic Thoracic Disc Herniation.

ObjectiveTo evaluate the clinical outcomes of transforaminal endoscopic thoracic discectomy (TETD) and microscopic discectomy (MD) for the treatment of symptomatic thoracic disc herniation (TDH). MethodsSeventy-seven patients (mean, 55.9 years; follow-up, 11.2 months) with symptomatic TDH were retrospectively reviewed (39 TETD and 38 MD). Radiological factors and perioperative outcomes were reviewed. Visual analogue scale (VAS), Oswestry Disability Index (ODI), and American Spinal Injury Association impairment scale were used to evaluate clinical and functional outcomes. Patient satisfaction was evaluated using modified MacNab criteria. ResultsThe levels of surgery and the location of hernia were evenly distributed in the both groups. The operative time (70.6 minutes vs. 175.7 minutes), estimated blood loss (3.8 mL vs. 357.4 mL), and length of hospital stay (7.0 days vs. 13.0 days) were significantly different between the TETD and MD groups (p<0.05). VAS scores for dorsal back pain and ODI scores were significantly improved in both groups (p<0.05). Patients who underwent TETD tended to be more satisfied with the outcome in terms of the modified MacNab criteria (89.7% vs. 73.0%, p=0.059). Two patients in the MD group underwent revision surgery, whereas one patient in the TETD group underwent MD because of incomplete decompression. ConclusionTETD for the symptomatic TDH is a feasible and safe procedure that could be used for a wider range of surgical levels with a shorter operative time and hospital stay and less blood loss. While achieving similar outcomes, TETD achieved better patient satisfaction because of the use of local anesthesia and its minimal invasiveness.

Surgeons Learning Curve of Transforaminal Endoscopic Discectomy for Sciatica.

ObjectiveFull-endoscopic spine surgery is gaining interest as a less-invasive alternative to treat sciatica caused by a lumbar disc herniation. Concerns, however, exist with the learning curve as percutaneous transforaminal endoscopic discectomy (PTED) appears to be more difficult to be performed compared to other techniques. In this study, the clinical outcomes during and after the learning curve are presented of 3 surgeons naïve to PTED. MethodsIn the first phase of a randomized controlled, noninferiority trial comparing PTED with microdiscectomy, 3 surgeons were trained in the PTED-procedure by a senior surgeon. After performing up to 20 cases under supervision, they started performing PTED on their own. Results of the early cases were compared to the later cases (>20). Furthermore, complications and reoperations were compared. Finally, differences in clinical outcomes between surgeons were compared. ResultsAt 12 months of follow-up, 87% of the patients had follow-up data available. In general, there were no significant differences in patient-reported outcomes between the early and later PTED cases. Furthermore, outcomes of the early PTED cases were comparable to the outcomes of microdiscectomy, while the later PTED cases had small, but more favorable outcomes compared to microdiscectomy. Two learning curve surgeons had substantially higher rates of reoperations within 1 year, compared to the senior surgeon or the microdiscectomy group. Duration of surgery was also longer for all learning curve surgeons. Finally, when comparing clinical outcomes of patients undergoing PTED versus microdiscectomy, there appears to be some statistically significant differences in outcomes compared between the senior and 3 learning curve surgeons. ConclusionPTED appears to be safe to be adopted by surgeons naïve to the procedure when they are initially supervised by an experienced senior surgeon. Duration of surgery and risk of repeated surgery are increased during the learning curve, but patient-reported outcomes of the early PTED cases are similar to the outcomes of later PTED cases, and similar to the outcomes of microdiscectomy cases. This study underlines the need for an experienced mentor for surgeons to safely adopt PTED.

Assessing the Learning Process of Transforaminal Endoscopic Discectomy for Sciatica.

ObjectivePercutaneous transforaminal endoscopic discectomy (PTED) is gaining popularity by both surgeons and patients as a less invasive treatment option for sciatica. Concerns, however, exist for its learning curve. No previous study has assessed the learning process of PTED. Hereby we present the learning process of 3 surgeons learning PTED. MethodsThis analysis was conducted alongside a multicenter randomized controlled trial. After attending a cadaveric workshop, 3 spine-dedicated surgeons started performing PTED, initially under the supervision of a senior surgeon. After each 5 cases, and up to case 20, the learning process was evaluated using the validated questionnaires (objective structured assessment of technical skills [OSATS], global operative assessment of laparoscopic skills [GOALS]) and a 10-step checklist specifically developed for PTED. ResultsIn total, 3 learning curve surgeons performed a total of 161 cases. Based on self-assessment, surgeons improved mostly in the domains “time and motion,” “respect for tissue,” and “knowledge and handling of instruments.” Learning curve surgeons were more able to detect differences in performances on the OSATS than the senior surgeon. Based on the GOALS, the biggest improvements could be seen in “depth-perception” and “autonomy.” Based on the 10-item specific checklist, all surgeons performed all 10 steps by case 10, while only 1 surgeon performed all steps adequately by case 15. ConclusionBased on these study results, PTED appears to be successfully adopted stepwise by 3 spine-dedicated surgeons. From 15 cases on, most steps are performed adequately. However, more cases might be necessary to achieve good clinical results. Validated tools are needed to determine the cutoff when a surgeon should be able to perform PTED independently.

Objective Evaluation of CT Imaging in the Treatment of Lumbar Disc Herniation.

The value of CT imaging in evaluating the efficacy of percutaneous transforaminal endoscopic discectomy (PTED) in the treatment of lumbar disc herniation (LDH) is explored. A total of 105 patients with LDH admitted to our hospital from March 2018 to September 2019 are selected for treatment with PTED, and all patients undergo CT examination before and after surgery. The CT imaging parameters (CT value of spinal canal soft tissue shadow, maximum back shift distance, longitudinal axis length, and intervertebral space height) before and 1 week after operation, the Japanese Orthopaedic Association (JOA) scores before and 6 months after the operation are compared, and the excellent and good rate of the operation effect is calculated. The correlation between JOA score and CT imaging parameters are analyzed by Pearson correlation method. The experimental results prove that PTED is effective in treating LDH. CT imaging can quantitatively measure the data of herniated intervertebral discs to clarify the recovery of the compressed dural sac and nerve roots, and the results are highly consistent with JOA score, which can be used as PTED objective evaluation method for the treatment of LDH.

Clinical efficacy of transforaminal endoscopic lumbar discectomy for lumbar degenerative diseases: A minimum 6-year follow-up.

BackgroundTransforaminal Endoscopic Lumbar Discectomy (TELD) is widely applied for lumbar degenerative disease (LDDs) and satisfactory short-term outcomes have been achieved. However, the mid-term and long-term follow-up of this technique is still lacking.ObjectiveTo retrospectively analyze the mid-term clinical efficacy of TELD for single-level LDD and its effect on intervertebral disc degeneration with a minimum of 6-year follow-up.Methods64 patients with single-level LDDs (lumbar disc herniation, lumbar spinal stenosis) who underwent TELD under local anesthesia in our department from December 2014 to December 2015 were observed. Visual analog scale (VAS), Japanese Orthopaedic Association evaluation treatment (JOA) score and Oswestry Disability Index (ODI) were calculated and compared before operation, 3 months after operation, 6 months after operation, 1 year after operation and at the last follow-up. Disc Height (DH), disc range of motion (ROM) and disc degeneration on standard lumbar lateral radiographs before operation and at the last follow-up were determined. Recurrence rate and operation-related complications during follow-up were recorded.Results64 cases were followed up for 6.4 ± 0.1 years. There were no complications such as infection, epidural hematoma and nerve root injury. 1 patient (1.67%) was found to have dural rupture and cauda equina hernia during the operation. There were significant differences in VAS, JOA, ODI between preoperative and postoperative 3 months, 6 months, 1 year and last follow-up (P < 0 01), VAS, JOA, ODI at 3 months after operation were different from 6 months after operation (P < 0 05), and there were significant differences compared with preoperative, 1 year after operation and last follow up (P < 0 01). VAS, JOA and ODI at 6 months after operation were significantly different from those before operation (P < 0.01), but not significantly different from those at 1 year after operation and the last follow-up (P > 0.05). There was no significant difference in DH, ROM and the Pfirrmann grade of intervertebral disc preoperative and the last follow-up. During the follow-up period, 3 patients (4.69%) were recurrent, 13 patients (20.31%) had various degrees of postoperative dysesthesia (POD), and 3 patients (4.69%) had various degrees of muscle weakness.ConclusionTELD has a satisfactory mid-term efficacy, and has no significant effect on the DH, the stability of the intervertebral disc space, or on intervertebral disc degeneration. However, as expected, TELD was associated with some complications including recurrent disc herniation and POD.

Risk Factors Involved in the Early and Medium-Term Poor Outcomes of Percutaneous Endoscopic Transforaminal Discectomy: A Single-Center Experience.

ObjectiveTo investigate the risk factors involved in the early and medium-term poor outcomes of percutaneous endoscopic transforaminal discectomy (PETD) treatment of lumbar disc herniation (LDH) at the L4-5 level.MethodsBetween January 2015 and May 2020, we recruited 148 LDH patients at the L4-5 level who underwent PETD surgery. The patients were divided into Groups A and B, according to the surgical outcomes. Good and excellent outcomes were categorized into Group A, and generally good and poor outcomes were categorized into Group B. Clinical parameters (age, gender, symptom duration, hospital stay, operation time, blood loss, straight-leg raising (SLR), visual analog scale (VAS), Oswestry Disability Index (ODI) score and modified MacNab criteria) and radiologic parameters (foraminal height (FH), intervertebral height index (IHI), intervertebral angle (IVA), sagittal range of motion (sROM), and lumbar lordosis (LL)) were collected and analyzed using univariate and multiple logistic regression analyses.ResultsAt the 6-month follow-up post operation, univariate analysis revealed that the symptom duration, SLR, IHI, and sROM were strongly associated with poor outcomes. However, multiple logistic regression analysis demonstrated that prolonged symptom duration, large SLR angel, and large sROM were independent risk factors for poor outcomes. At the 2-year follow-up post operation, univariate analysis suggested that advanced age, prolonged symptom duration, large preoperative VAS score, small FH, small IHI, and large sROM were potential risk factors for poor outcomes. However, multiple logistic regression analysis demonstrated that prolonged symptom duration, small IHI, and large sROM were independent risk factors for poor outcomes.ConclusionOur study demonstrated that prolonged symptom duration, large SLR angel, and large sROM were independent risk factors for poor outcomes immediately following PETD at the L4-5 level. However, prolonged symptom duration, small IHI, and large sROM were independent risk factors for poor outcomes at medium-term post PETD at the L4-5 level.

Citation analysis of the 100 top-cited articles on discectomy via endoscopy since 2011 using alluvial diagrams: bibliometric analysis

BackgroundPercutaneous endoscopic lumbar discectomy (PELD) is synonymous with percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID). PEID has gained increasing recognition for its small incision, quick recovery, short hospital stay, and equivalent clinical outcome to open surgery. Numerous articles related to PEID have been published in the literature. However, which countries, journals, subject categories, and articles have ultimate influence remains unknown. The study aimed to (1) display influential entities in 100 top-cited PEID-related articles (T100PEID) on the alluvial diagram and (2) investigate whether medical subject headings (i.e., MeSH terms) can be used to predict article citations.MethodsT100PEID data can be found since 2011 in the PubMed and Web of Science (WOS) databases. Using alluvial diagrams, citation analysis was conducted to compare the dominant entities. We used social network analysis (SNA) to classify MeSH terms and research areas extracted from PubMed and WOS. The difference in article citations across subject categories and the predictive power of MeSH terms on article citations in T100 PEID were examined using one-way analysis of variance (ANOVA) and regression analysis.ResultsA total of 81% of T100PEID is occupied by the top three countries (the US, China, and South Korea). There was an overall T100PEID impact factor of 41.3 (IF = citations/100). Articles were published in Spine (Phila Pa 1976) (23%; IF = 41.3). Six subject categories were classified using the SNA. The most cited article authored by D Scott Kreiner from Ahwatukee Sports and Spine in the US state of Phoenix had 123 citations in PubMed. The network characteristics of T100PEID are displayed on the alluvial diagram. No difference was found in article citations among subject categories (F = 0.813, p = 0.543). The most frequently occurring MeSH term was surgery. MeSH terms were evident in the prediction power of the number of article citations (F = 15.21; p < 0 .001).ConclusionWe achieved a breakthrough by displaying the T100PEID network characteristics on the alluvial plateau. The MeSH terms can be used to classify article subject categories and predict T100PEID citations. The alluvial diagram can be applied to bibliometrics on 100 top-cited articles in future studies.

Analysis of Chronic Low Back Pain Caused by Lumbar Microinstability After Percutaneous Endoscopic Transforaminal Discectomy: A Retrospective Study.

ObjectiveChronic low back pain (CLBP) after percutaneous endoscopic transforaminal discectomy (PTED) surgery may be caused by preoperative lumbar microinstability (MI). However, there is a paucity of research on the relationship between lumbar microinstability and chronic low back pain. The purpose of this article is to assess the preoperative radiographic characteristics of patients and evaluate the effects of lumbar microinstability on patient-reported outcomes among single-level lumbar disc herniation (LDH) patients who underwent PTED.MethodsThis study retrospectively reviewed the radiographic characteristics of a consecutive series of 127 patients with low back pain and leg pain caused by single-level LDH underwent PTED from August 2018 to March 2021. They were divided into three groups according to the radiographic parameters: the stable group (Group S), the dysfunctional group (Group D), and the microinstability group (Group M). The visual analogue scale (VAS) scores for leg and low back pain and Oswestry Disability Index (ODI) were evaluated preoperatively and postoperatively. Logistic regression analysis was used to identify independent risk factors for CLBP.ResultsCompared with Group D and Group S, Group M had the highest ODI scores (P < 0.01) and VAS scores (low back pain) (P < 0.01) after 1 year, while there were no significant differences in the VAS scores for leg pain at different time points after surgery (P > 0.05). In addition, the logistic regression analysis results regarding CLBP revealed that muscle fatty degeneration on MRI (95% CI, 1.20–8.51, P = 0.02), and facet tropism (95% CI, 1.39 −11.37, P = 0.01) may be independent risk factors.ConclusionPatients with lumbar microinstability may have CLBP after PTED, so patients with lumbar microinstability may need to take internal fixation surgery to solve their symptoms.

86. Long-term cost-effectiveness of full endoscopic vs open discectomy: two-year results of a RCT

<h3>BACKGROUND CONTEXT</h3> Open microdiscectomy is a frequently performed surgical procedure for sciatica caused by lumbar disc herniation. Percutaneous transforaminal endoscopic discectomy (PTED) has been introduced as a less invasive alternative and 1-year results show non-inferiority in leg pain reduction and dominancy in cost-effectiveness. <h3>PURPOSE</h3> To compare the long-term cost-effectiveness of PTED with open microdiscectomy among patients with sciatica caused by lumbar disc herniation as measured at two years. <h3>STUDY DESIGN/SETTING</h3> Randomized controlled trial at four clinics in the Netherlands which ran from February 2016 to April 2019. <h3>PATIENT SAMPLE</h3> Patients were aged from 18 to 70 years and had at least 6 weeks of radiating leg pain caused by lumbar disc herniation. The trial included a predetermined set of 125 PTED patients who were the early cases performed by three surgeons who had not performed PTED before the trial. Eventually 304 patients were allocated to PTED and 309 to open microdiscectomy. <h3>OUTCOME MEASURES</h3> Primary effect measures included leg pain as measured on the VAS for leg pain and health-related quality of life (QALYs). Costs were measured from a societal perspective. <h3>METHODS</h3> An economic evaluation was conducted alongside the PTED trial. A cost-effectiveness analysis and a cost-utility analysis were conducted. The primary analysis was conducted according to the intention-to-treat approach. All missing data were imputed using multiple imputation by chained equations (MICE), stratified by treatment group. Predictive mean matching was used to create 10 complete datasets. Disaggregate cost differences were analyzed using linear regression models, both adjusted and unadjusted for confounders. Differences in total costs and effects between treatment groups were obtained from a system of seemingly unrelated regressions (SUR) that accounted for the potential correlation between costs and effects. These total cost and effect differences were adjusted for baseline and confounders. Incremental cost-effectiveness ratios were calculated by dividing incremental costs by incremental effects. Uncertainty was estimated by bootstrapping and presented using Cost-effectiveness Planes and Cost-Effectiveness Acceptability Curves. <h3>RESULTS</h3> At 24 months, 92% of the follow-up data were available. Statistically significant differences in leg pain and QALYs were found in favor of PTED at 24-month follow-up (leg pain: 7.3; QALYs: 0.043). Surgery costs were higher for PTED than for open microdiscectomy (ie, €4,500/patient vs €4,095/patient). All other disaggregate costs as well as total societal costs were lower for PTED than for open microdiscectomy, namely primary care, secondary care, medication, informal care, absenteeism, presenteeism and productivity loss. Per performed PTED procedure, €138 in health care costs and €2787 in societal costs are saved. Cost-effectiveness acceptability curves indicated that the probability of PTED being cost-effective compared with open microdiscectomy (meaning on average less costly and more effective) was 99.4% for leg pain and 99.2% for QALYs, regardless of the willingness-to-pay. <h3>CONCLUSIONS</h3> Results suggest that PTED is less costly and more effective, and therefore cost-effective compared with microdiscectomy for patients with sciatica from the societal perspective. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

P131. Long term effectiveness of full endoscopic versus open microdiscectomy for sciatica: a 24-month RCT

<h3>BACKGROUND CONTEXT</h3> Open microdiscectomy (OM) is the current standard procedure to treat sciatica caused by lumbar disk herniation. Percutaneous transforaminal endoscopic discectomy (PTED) is an alternative procedure which is performed under local anesthesia. Here we report the long-term results. <h3>PURPOSE</h3> To assess long-term effectiveness of PTED vs OM at 24 months. <h3>STUDY DESIGN/SETTING</h3> A pragmatic, multicenter, non-inferiority, randomized controlled trial. <h3>PATIENT SAMPLE</h3> A total of 613 were randomized to either PTED (n=304) or OM (n=309). <h3>OUTCOME MEASURES</h3> The primary outcome is self-reported leg pain measured by the 0-100 Visual Analogue Scale (VAS) with a noninferiority margin of 5. Secondary outcomes include self-reported ODI, back pain, health-related quality of life and self-perceived recovery. <h3>METHODS</h3> A pragmatic, multicenter, non-inferiority, randomized controlled trial was conducted in which patients were randomized between PTED or OM in a 1:1 ratio. The primary outcome is self-reported leg pain measured by the 0-100 visual analogue scale (VAS) with a noninferiority margin of 5. Secondary outcomes include self-reported ODI, back pain, health-related quality of life and self-perceived recovery. Outcomes were measured the day following surgery, at 2, 4, and 6 weeks, and at 3, 6, 9,12 and 24 months. <h3>RESULTS</h3> At 24 months, 92% of the patients had followup data available. At 24 months, the adjusted between group difference of the VAS leg pain was 7.3 in favor of PTED (17.0 ± 22.4 vs 24.3 ± 26.5;). There was no difference in back pain at 24 months between both groups. All other secondary patient-reported outcomes showed small but statistically more favorable results for the PTED-group. Complications rates and rate of recurrent disc surgery appear similar between both groups. <h3>CONCLUSIONS</h3> At long-term, PTED remains noninferior to OM in the treatment of sciatica at 24 months of followup and clinical outcomes appear to be more favorable for PTED, albeit not exceeding established MCIDs. Therefore, based on these study results, implementation of PTED as a treatment option for sciatica is warranted. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Efficacy and safety of epidural anesthesia versus local anesthesia in percutaneous transforaminal endoscopic discectomy: a systematic review and meta-analysis.

For some patients, local anesthesia (LA) in percutaneous transforaminal endoscopic discectomy (PTED), especially during canal shaping and discectomy, is insufficient for analgesia. Epidural anesthesia (EA) is infrequently applied in PTED but reports satisfactory results. Previous studies present conflicting results in analgesia satisfactory and adverse events. Differences in surgery details and small sample size might explain conflicting results. Meta-analysis pools the results from individual studies to create a larger sample size and provides a more reliable conclusion. The aim of this study is to evaluate the efficacy and safety of EA in PTED. The search terms "percutaneous transforaminal endoscopic discectomy" and "anesthesia" are used to search Cochrane, Web of Science, PubMed, Embase, OVID, China National Knowledge Infrastructure (CNKI), VIP, and Wanfang from inception to 2021-08. Inclusion criteria is defined according to PICOS principals: P (patients): patients are diagnosed with lumbar disc herniation or spinal canal stenosis. I (intervention): patients undergo PTED under EA. C (comparisons): patients undergo PTED under LA. O (outcomes): primary outcomes: intraoperative visual analogue scale (VAS), anesthesia satisfactory, sufentanil usage. Secondary outcomes: adverse events, surgery exit, bleed volume, X-ray radiation. S (study design): randomized controlled trials (RCTs). The Cochrane RoB 2.0 is used to evaluate the quality of the included studies. Authors perform meta-analysis through Review Manager 5.4. A total of 6 studies representing 529 patients are included: EA group includes 261 patients, and LA group includes 268 patients. All studies lack design of allocation concealment and blinding of participants and personnel. Only Luo reports blinding of outcome assessment in 2019. Meta analysis concludes that EA is superior in intraoperative analgesic [mean difference (MD) =-4.31; 95% confidence interval (CI): -4.52 to -4.09; P<0.00001], anesthesia satisfactory [odds ratio (OR) =10.06; 95% CI: 2.41 to 41.98; P=0.002], sufentanil usage (MD =-9.12; 95% CI: -10.34 to -7.90; P<0.00001), adverse events (OR =0.19; 95% CI: 0.07 to 0.52; P=0.001). There is no difference in bleed volume (MD =-2.61; 95% CI: -5.45 to 0.23; P=0.07), exit rate (OR =0.23; 95% CI: 0.04 to 1.35; P=0.10) and future effects (MD =-0.23; 95% CI: -0.50 to 0.03; P=0.08). EA is an effective and safe anesthesia method for PTED and might achieve better clinical results than LA. More high-quality research is needed to provide high-quality evidence for efficacy and safety.

Percutaneous Endoscopic Discectomy Via a Transforaminal Approach for L5/S1 Far-Lateral Disc Herniation Assisted by Intraoperative Computed Tomography

To examine the clinical outcomes of a percutaneous lumbar transforaminal endoscopic discectomy (PTED) with intraoperative computed tomography (iCT) navigation for the treatment of L5-S1 far-lateral lumbar disc herniation (LDH). A total of 30 patients with L5-S1 far-lateral LDH who underwent PTED with iCT navigation from September 2016 to October 2020 were enrolled in this study. Outcomes were assessed using the visual analog scale pain score, the Oswestry Disability Index, the Japanese Orthopedic Association score, the EQ-5D-5L and the modified Macnab criteria. Preoperative and postoperative complications were recorded. The mean visual analog scale score for leg pain improved from 8.1 at baseline to 2.3, 0.9, 0.7 and 0.9 at 1day, 1week, 6months, and 12months postoperatively, respectively (P < 0.01). The mean Oswestry Disability Index improved from 78.1% at baseline to 45.5%, 21.9%, 12.6%, and 11.7% at 1week, 1month, 6months, and 12months postoperatively, respectively (P < 0.01); and the mean Japanese Orthopedic Association score improved from 8.6 at baseline to 14.2, 20.2, 24.4, and 25.6 at 1day, 1week, 6months, and 12months postoperatively, respectively (P < 0.01). At 12months postoperatively, the EQ-5D-5L value significantly increased, from-0.061±0.138 to 0.903±0.064. The rate of a good or excellent modified Macnab result was 93% (26/28) at 12months postoperatively. In the present study, combined L5-S1 foraminal stenosis tended to lead poor outcomes, which required more postsurgical treatments. With iCT navigation, PTED is a feasible and effective minimally invasive surgery for L5-S1 far-lateral LDH.

Comparing the Effectiveness and Safety Between Local Anesthesia versus Epidural Anesthesia for Percutaneous Transforaminal Endoscopic Discectomy: A Systematic Review and Meta-Analysis

The objective of this study was to compare the effectiveness and safety of local anesthesia (LA) and epidural anesthesia (EA) for percutaneous transforaminal endoscopic discectomy (PTED) and provide reference data for clinical decision-making. We searched PubMed, EMBASE, the Cochrane library, Web of Science, Medline, Science Direct, and China National Knowledge Infrastructure from inception to March 2022 to identify randomized and nonrandomized controlled trials comparing LA and EA for PTED. Studies that assessed at least 2 of the following indicators were considered eligible: surgical duration, X-ray exposure time, satisfaction rate, visual analog scale scores for pain, Oswestry Disability Index, and complications. Meta-analysis was conducted using Review Manager 5.3.3 software. Five randomized controlled trials and 5 retrospective cohort studies involving a total of 1660 patients were included. The LA and EA groups included 803 and 857 patients, respectively. Meta-analysis revealed significant intergroup differences in the intraoperative lumbar visual analog scale scores (P < 0.00001) and anesthesia satisfaction rate (P < 0.00001). There were no significant intergroup differences in the surgical duration, X-ray exposure time, postoperative Oswestry Disability Index, and complication rate. EA is as safe as LA and produces better anesthetic effects than LA in patients undergoing PTED. Therefore, EA should be promoted as a reliable anesthetic technique for PTED.