Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study

Endoscopic Versus Traditional Thoracic Discectomy: A Multicenter Retrospective Case Series and Meta-Analysis

BACKGROUND AND OBJECTIVES

Surgical treatment for symptomatic thoracic disc herniations (TDH) involves invasive open surgical approaches with relatively high complication rates and prolonged hospital stays. Although advantages of full endoscopic spine surgery (FESS) are well-established in lumbar disc herniations, data are limited for the endoscopic treatment of TDH despite potential benefits regarding surgical invasiveness. The aim of this study was to provide a comprehensive evaluation of potential benefits of FESS for the treatment of TDH.

METHODS

PubMed, MEDLINE, EMBASE, and Scopus were systematically searched for the term "thoracic disc herniation" up to March 2023 and study quality appraised with a subsequent meta-analysis. Primary outcomes were perioperative complications, need for instrumentation, and reoperations. Simultaneously, we performed a multicenter retrospective evaluation of outcomes in patients undergoing full endoscopic thoracic discectomy.

RESULTS

We identified 3190 patients from 108 studies for the traditional thoracic discectomy meta-analysis. Pooled incidence rates of complications were 25% (95% CI 0.22-0.29) for perioperative complications and 7% (95% CI 0.05-0.09) for reoperation. In this cohort, 37% (95% CI 0.26-0.49) of patients underwent instrumentation. The pooled mean for estimated blood loss for traditional approaches was 570 mL (95% CI 477.3-664.1) and 7.0 days (95% CI 5.91-8.14) for length of stay. For FESS, 41 patients from multiple institutions were retrospectively reviewed, perioperative complications were reported in 4 patients (9.7%), 4 (9.7%) required revision surgery, and 6 (14.6%) required instrumentation. Median blood loss was 5 mL (IQR 5-10), and length of stay was 0.43 days (IQR 0-1.23).

CONCLUSION

The results suggest that full endoscopic thoracic discectomy is a safe and effective treatment option for patients with symptomatic TDH. When compared with open surgical approaches, FESS dramatically diminishes invasiveness, the rate of complications, and need for prolonged hospitalizations. Full endoscopic spine surgery has the capacity to alter the standard of care for TDH treatment toward an elective outpatient surgery.

Contrast enhancing epidural fluid accumulation after percutaneous endoscopic lumbar discectomy: A case report of recurrent disc herniation within pseudocyst secondary to irrigation fluid

INTRODUCTION

Percutaneous endoscopic lumbar discectomy (PELD) is increasingly being utilized to treat patients with lumbar disc herniation. PELD is unique in that it uses a single working port endoscope with constant irrigation of the surgical field to visualize pathology. The current report is of a case of postoperative epidural irrigation fluid accumulation presenting as peripherally enhancing epidural lesions, masking an underlying re-herniation.

PRESENTATION OF CASE

A patient with a Lumbar 5-Sacral 1 level disc herniation presenting with radiculopathy was treated using PELD. Following the operation, the patient experienced recurrent pain, prompting a repeat MRI of the lumbar spine. Multiple ring-enhancing lesions within the epidural space were observed, creating diagnostic dilemmas. The differential diagnoses included epidural abscess, pseudomeningocele from unintended durotomy, epidural hematoma, or trapped epidural fluid collection presenting as a pseudocyst with or without recurrent disc herniation. A repeat endoscopic discectomy was performed to confirm the diagnosis of pseudocyst, revealing a recurrent disc herniation.

DISCUSSION

Pseudocysts are not an uncommon complication of PELD, typically believed to be due to an inflammatory response to disc fragments. However, in this case, the epidural fluid collection was likely the result of trapped irrigation fluid from continuous irrigation during the procedure, which masked an underlying re-herniation on imaging.

CONCLUSION

With the increasing utilization of PELD, it is important to acknowledge unique complications such as fluid accumulation from irrigation within the epidural space. Fluid accumulation can lead to contrast-enhancing pseudocyst formation, which can theoretically lead to mass effect or increased intracranial and intraspinal pressure and may mask additional underlying pathology.

Transforaminal Endoscopic Ventral Stenosis Decompression in Calcified Lumbar Disc Herniation: A Long Term Outcome in 79 Patients

BACKGROUND

Calcified lumbar disc herniations (CLDH) causing calcified ventral stenosis pose a therapeutic challenge to the treating surgeon due to their neural adhesions, location, and hardness.

METHODS

This retrospective study analyzed all the cases of CLDH/calcified ventral stenosis managed by transforaminal endoscopic lumbar discectomy with a minimum follow-up of 24 months. The preoperative images were analyzed for the level, migration; and grade (Lee's migration zones), and location (Michigan State University classification). Detailed surgical technique and intraoperative parameters including the duration of surgery and complications have been recorded. The clinical parameters including visual analog scale (VAS), Oswestry disability index (ODI), length of stay in hospital, days of return to basic work, and patient satisfaction index were analyzed. Postoperatively the images were analyzed for the adequacy of decompression.

RESULTS

The mean VAS for back pain and leg pain was 4.7 ± 2.6 (0-9), and 7.45 ± 2.2 (1-10), respectively. The mean preoperative ODI was 78.2 ± 13.2 (63.2-95.6). Nineteen patients (24%) had neurological deficits preoperatively. The mean duration of surgery was 90.5 ± 15.8 (58-131) minutes. Postoperative magnetic resonance imaging revealed adequate decompression in 97.5% (n = 77). The mean duration of hospital stay was 1.05 ± 0.22 (1-2) days, and the postoperative back and leg pain VAS was 1.14 ± 1.2 (0-3) (P < 0.05) and 1.7 ± 0.5 (0-6) (P < 0.05), respectively. The ODI at final follow-up was 6.5 ± 3.7 (2.2-18) (P < 0.05). Neurological recovery occurred in 17 (89.5%) patients and they returned to basic work/jobs in 19.5 ± 3.3 (14-26) days. The mean patient satisfaction index was 1.18 ± 0.47 (1-2) at a mean follow-up of 5.52 ± 2.91 (2-12.75) years.

CONCLUSIONS

Transforaminal endoscopic lumbar discectomy is a complete, safe, and efficacious procedure in patients with CLDH with earlier recovery considering the surgery is performed with the patient being awake.

Evolution, Current Trends, and Latest Advances of Endoscopic Spine Surgery

Background: The aging of the population in developing and developed countries has led to a significant increase in the health burden of spinal diseases. These elderly patients often have a number of medical comorbidities due to aging. The need for minimally invasive techniques to address spinal disorders in this elderly population group cannot be stressed enough. Minimally invasive spine surgery (MISS) has several proven benefits, such as minimal muscle trauma, minimal bony resection, lesser postoperative pain, decreased infection rate, and shorter hospital stay. Methods: A comprehensive search of the literature was performed using PubMed. Results: Over the past 40 years, constant efforts have been made to develop newer techniques of spine surgery. Endoscopic spine surgery is one such subset of MISS, which has all the benefits of modern MISS. Endoscopic spine surgery was initially limited only to the treatment of lumbar disc herniation. With improvements in optics, endoscopes, endoscopic drills and shavers, and irrigation pumps, there has been a paradigm shift. Endoscopic spine surgery can now be performed with high magnification, thus allowing its application not only to lumbar spinal stenosis but also to spinal fusion surgeries and cervical and thoracic pathology as well. There has been increasing evidence in support of these newer techniques of spine surgery. Conclusions: For this report, we studied the currently available literature and outlined the historical evolution of endoscopic spine surgery, the various endoscopic systems and techniques available, and the current applications of endoscopic techniques as an alternative to traditional spinal surgery.

Endoscopic Treatment of Lumbar Degenerative Disc Disease: A Narrative Review of Full-Endoscopic and Unilateral Biportal Endoscopic Spine Surgery

BACKGROUND

Degenerative lumbar spine disease is the leading cause of disability and work absenteeism worldwide. Lumbar microdiscectomy became the standard treatment for herniated discs and stenotic disease. With the evolution of different techniques, endoscopic spinal surgery emerged to minimize the surgical footprint while providing at least non-inferior results. Currently, two different types of endoscopic spine procedures are dominating the surgical scenario: "Full-Endoscopic" (FE) and Unilateral Biportal Endoscopic" (UBE) Spine Surgery. The aim of this study is to describe and analyze their indications, their technical characteristicswithitsadvantagesanddisadvantagesofbothtechniquesandtheirfuture trends.

METHODS

We performed a narrative review of the most relevant articles published up to August 2023 through a Pub Med search. The search terms " FE Spine Surgery" and " UBE Spine Surgery" were used. The articles selected, were independently reviewed by 3 authors and 55 full text articles were reviewed.

RESULTS

The FE and UBE Spine Surgery techniques were described. The FE technique is performed with a monoportal access under constant saline irrigation. The FE comprises the transforaminal and the interlaminar approaches, and the indication depends from the pathology to treat, and still remains controversial. UBE can approach also the spine from a posterior, postero lateral,and para spinal route. It uses two different ports addressed to a target with continuous irrigation. The process of establishing these two portals is called triangulation.

CONCLUSIONS

FE and UBE spine surgery have demonstrated outcomes comparable to open surgery, minimizing complications and surgical footprint.

Modified Percutaneous Endoscopic Interlaminar Discectomy through the Near-spinous Process Approach for L4/5 Disc Herniation: A Retrospective Clinical Study

OBJECTIVE

Compared with traditional open surgery, percutaneous endoscopic lumbar discectomy (PELD) has the advantages of less trauma, faster recovery, and less postoperative pain, so it has been widely used in the field of spinal surgery. However, it still has the defect of intraoperative fluoroscopy occurrences, complications, and even the risk of damage to the spinal cord and nerve. This study aims to compare the clinical efficacy of modified percutaneous endoscopic interlaminar discectomy (MPEID) with percutaneous endoscopic transforaminal discectomy (PETD) in treating L4/5 lumbar disc herniation (LDH) and to evaluate the effectiveness and safety of MPEID.

METHODS

Thirty-four L4/5 LDH patients treated at the Second Affiliated Hospital of Nanchang University from June 2020 to June 2021 were studied retrospectively. Seventeen underwent MPEID and seventeen PETD. Variables analyzed included demographics, operative duration, intraoperative fluoroscopy occurrences, and surgical outcomes. Effectiveness was evaluated using the visual analogue scale (VAS), Oswestry disability index (ODI), and modified MacNab criteria. Lumbar Magnetic Resonance Imaging (MRI) was used to assess radiological outcomes. A paired t-test was performed to compare intragroup pre- and postoperative clinical data, VAS, and ODI scores.

RESULTS

The average operative time in PETD group was 91.65 ± 14.04 min, and the average operative time in MPEID group was 65.41 ± 12.61 min (p < 0.001). In PETD group, the fluoroscopy occurrences averaged 9.71 ± 1.05 times, with fluoroscopy occurrences averaging 6.47 ± 1.00 times (p < 0.001) in MPEID group. At 12 months follow-up, the clinical effect showed significant improvement in both two groups. The MPEID group showed a decrease in average VAS-back score from 5.41 ± 2.18 to 1.76 ± 1.09 (p < 0.001) and VAS-leg score from 6.53 ± 1.66 to 0.82 ± 0.64 (p < 0.001). The ODI scores decreased from 51.35 ± 10.65 to 11.71 ± 2.91 (p < 0.001). In the PETD group, the VAS-back score decreased from 4.94 ± 1.98 to 2.06 ± 1.25 (p < 0.001), VAS-leg score from 7.12 ± 1.73 to 1.12 ± 0.60 (p < 0.001), and ODI scores from 48.00 ± 11.62 to 12.24 ± 2.56 (p < 0.001). According to the modified MacNab criteria, MPEID had 15 excellent and two good results; PETD had 12 excellent and 5 good (p = 0.23). No nerve root injuries, dural tears, or significant complications were reported.

CONCLUSION

MPEID and PETD effectively treat L4/5 LDH, with MPEID showing shorter operative times and fewer fluoroscopies. Furthermore, the MPEID group can provide excellent clinical efficacy as the PETD group in the short term.

Access to the Lumbosacral Spine: A Current View

The surgical approach to the lumbosacral spine has been the subject of experimental and scientific anatomical studies since the Hippocratic era. However, it was in the 20th century that, with the evolution of asepsis and antibiotic therapy, spine surgery began to evolve at breakneck speed, and the various possibilities of access roads became objects of development and discussion. As a result, pathologies of the lumbosacral spine can be accessed in different ways and positions, from the traditional posterior approach in the prone position to the anterior, oblique, lateral, and endoscopic approaches. The current article brings state-of-the-art access routes to the lumbosacral spine. This article objective is to elucidate the possibilities of accesses the lumbar spine for any purposes, as decompression, fusion, tumour resections, reconstruction or deformity correction, despites type of implants or implants positioning.

Minimally Invasive Treatment for Lumbar Disc Herniation: A Matched Comparison Between Tubular Microdiscectomy and Percutaneous Endoscopic Lumbar Discectomy

Background and objectives Discectomy for lumbar disc herniation is the most common spinal surgical procedure. Technological advances have led to the emergence of minimally invasive surgical approaches such as tubular microdiscectomy (TMD) and percutaneous endoscopic lumbar discectomy (PELD). The purpose of this study was to compare the clinical outcomes of PELD to those of TMD at one-year follow-up. Materials and methods This observational registry-based (Spine Tango) cohort study included patients with symptomatic lumbar disc herniation submitted to PELD or TMD. The inclusion criteria were patients who underwent minimally invasive lumbar discectomy (PELD or TMD), patients who attended a follow-up after a minimum of 12 months post surgery, and valid pre- and postoperative questionaries. The primary endpoint was defined as the difference between pre- and postoperative Core Outcome Measures Index (COMI) for the back. The matching was based on a 1:1 nearest neighbor matching without replacement. Results A total of 109 patients were included in this study. Propensity score matching (PSM) was performed achieving 86 patients in the matched sample. Regarding COMI improvement, we found no significant difference between the PELD and TMD groups (paired t-test: estimate, -0.23; standard error, 0.6; p=0.7), and we also did not find any significant difference between groups concerning Oswestry Disability Index (ODI) and EuroQol 5 Dimension (EQ-5D). Medication usage and return to work were similar among the matched groups. Conclusions PELD is a technique that minimizes tissue damage achieving good clinical outcomes similar to TMD. This was observed one year after surgery from patient-reported outcome measures (PROMs) that measured pain improvement, disability, and quality of life.

Endoscopic Lumbar Disc Surgery Experience with the TESSYS Technique in 253 Case Series

Background: Herniated lumbar disc (HLD) is a widespread medical problem which can require surgery. Minimally invasive surgical management can represent an extremely valuable option for patients suffering from HLDs. Transforaminal endoscopic lumbar discectomy is an alternative to classical microdiscectomy which was proposed more than two decades ago and has evolved technologically with time. Methods: The transforaminal endoscopic spine system (TESSYS) technique has been introduced in recent years and offers the advantage of performing a controlled foraminal augmentation with full nerve root protection. We started using this technique in 2016 and prospectively evaluated the results of endoscopic TESSYS-based operations performed in a three-year period until the end of 2019. Selection criteria were very strict, and we included only patients with unilateral radicular pain with no instability who failed conservative therapy. Out of the 253 patients operated on in that time span, 183 were available for follow-up evaluation. Results: After surgery, there was a clinically significant improvement of all symptoms which basically lasted in the long-term follow-up. Complications were limited and generally minor. Redo surgery with microdiscectomy was required only in four cases. Obesity did not play a clear negative role in patients' outcome. Conclusions: Endoscopic transforaminal discectomy with the TESSYS technique represents a valuable management option for patients harbouring unilateral herniated lumbar disc located laterally.

Advances and Challenges of Endoscopic Spine Surgery

The purpose of this paper is to review the data supporting current endoscopic surgical techniques for the spine and the potential challenges and future of the field. The origins of endoscopic spine surgery can be traced back many decades, with many important innovations throughout its development. It can be applied to all levels of the spine, with many robust trials supporting its clinical outcomes. Continued clinical research is needed to explore its expanding indications. Although the limitations of starting an endoscopic program can be justified by its cost effectiveness and positive societal impact, challenges facing its widespread adoption are still present. As more residency and fellowship programs include endoscopy as part of their spine training, it will become more prevalent in hospitals in the United States. Technological advancements in spine surgery will further propel and enhance endoscopic techniques as they become an integral part of a spine surgeon's repertoire.

How I do it: dual operation channels percutaneous endoscopic far-lateral transforaminal lumbar interbody fusion

BACKGROUND

The current surgical procedure of interbody fusion in the lumbar spine has several limitations including low efficiency, potential endplate damage, overdose radiation exposure, and failure of fusion.

METHODS

Through the endoscopic operating channel, we efficiently removed the superior and inferior articular processes and decompressed the ligamentum flavum. Another operating channel was established under endoscopic monitoring to excise the annulus fibrosus, remove the cartilaginous endplate using open instruments, perform interbody bone grafting, and place a non-expandable polyetheretherketone open surgical fusion cage.

CONCLUSION

Lumbar interbody fusion was performed successfully using a far-lateral transforaminal approach combined with dual operation channels of percutaneous endoscopic-assisted technique.

Transforaminal endoscopic lumbar foraminotomy for octogenarian patients

Background

Radiculopathy caused by lumbar foraminal stenosis in older people has become more common in the aging general population. However, patients aged ≥80 years rarely undergo conventional open surgery under general anesthesia because of the high risk of peri-operative morbidity and adverse events. Therefore, less invasive surgical alternatives are needed for older or medically handicapped patients. Transforaminal endoscopic lumbar foraminotomy (TELF) under local anesthesia may be helpful in at-risk patients, although only limited information is available regarding the clinical outcomes of this procedure in octogenarians. Therefore, this study aimed to investigate the safety and efficacy of TELF for treating radiculopathy induced by foraminal stenosis in octogenarian patients.

Methods

Overall, 32 consecutive octogenarian patients with lumbar foraminal stenosis underwent TELF between January 2019 and January 2021. The inclusion criterion was unilateral radiculopathy secondary to lumbar foraminal stenosis. The pain focus was confirmed using imaging studies and selective nerve blocks. Full-scale foraminal decompression was performed using a percutaneous transforaminal endoscopic approach under local anesthesia. Surgical outcomes were assessed using the visual analog pain score, Oswestry Disability Index, and modified MacNab criteria.

Results

The pain scores and functional outcomes improved significantly during the 24-month follow-up period, and the rate of clinical improvement was 93.75% in 30 of the 32 patients. None of the patients experienced systemic complications.

Conclusion

TELF under local anesthesia is an effective and safe treatment for foraminal stenosis in octogenarian or medically compromised patients. The mid-term follow-up did not reveal any significant progression in spinal stability. Therefore, this endoscopic procedure can be an effective alternative to aggressive surgery for managing lumbar foraminal stenosis in octogenarian patients with intractable radiculopathy.

Predictors of Clinical Failure after Endoscopic Lumbar Spine Surgery During the Initial Learning Curve

OBJECTIVE

This study aims to identify clinical factors that may predict failed endoscopic lumbar spine surgery to guide surgeons with patient selection during the initial learning curve.

METHODS

This is an Australasian prospective analysis of the first 105 patients to undergo lumbar endoscopic spine decompression by 3 surgeons. Modified MacNab outcomes, visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were utilized to evaluate clinical outcomes at 6 months postoperatively. Descriptive statistics and ANOVA t tests were performed to measure statistically significant (P < 0.05) associations between variables using GraphPad Prism v10.

RESULTS

Patients undergoing endoscopic lumbar surgery via an interlaminar or transforaminal approach have overall good/excellent modified MacNab outcomes and a significant reduction in postoperative VAS and ODI scores. Regardless of the anatomic location of disc herniations, good/excellent modified MacNab outcomes and significant reductions in VAS and ODI were reported post-operatively, however, not in patients with calcified disc herniations. Patients with central and foraminal stenosis overall reported poor/fair modified MacNab outcomes, however, there were significant reductions in VAS and ODI scores postoperatively. Patients with subarticular stenosis or an associated spondylolisthesis reported good/excellent modified MacNab outcomes and significant reductions in VAS and ODI scores postoperatively. Patients with disc herniation and concurrent degenerative stenosis had generally poor/fair modified MacNab outcomes.

CONCLUSIONS

The outcomes of endoscopic spine surgery are encouraging with low complication and reoperation rates. However, patients with calcified disc herniations, central canal stenosis, or disc herniation with concurrent degenerative stenosis present challenges during the initial learning curve and may benefit from traditional open or other minimally invasive techniques.

Postoperative MRI Findings Following PELD and Their Correlations with Clinical Prognosis are Investigated by Injecting Contrast into Annulus Fibrosus Intraoperatively

Objective

To validate whether a residual mass demonstrated on early postoperative MR after percutaneous endoscopic lumbar discectomy (PELD) is indeed an intraoperatively retained annulus fibrosus, and explore the correlation between imaging changes in the residual mass and clinical prognosis of patients.

Methods

A prospective study of 118 patients were included. During surgery, a contrast medium, Gadopentetate Dimeglumine, was injected around the ruptured annulus fibrosus. The intensity of the T2 signal, the size of the remaining mass (SR), and the cross-sectional area of the spinal canal (SCSA), VAS, and ODI were assessed at preoperative, 1-h (7-day), 6-month, and 12-month postoperative intervals. Based on VAS at 7 days post-surgery, patients were classified into either a non-remission group (Group A, VAS > 3) or a remission group (Group B, VAS ≤ 3).

Results

Six patients who developed recurrent LDH were excluded. A residual mass was detected on MRI 1 h after surgery in 94.6% (106/112). During one year of follow-up, 90.1% (101/112) of the patients displayed fibrous annulus remodeling, although 68.7% (77/112) still exhibited herniation. Significant differences were found in the ODI between Groups A and B one week after surgery (p < 0.001). However, no significant differences were observed in T2 signal intensity, SR, and SCSA at 1-h, 6-month and 12-month post-surgery (p > 0.05) between the two groups. In a multiple linear regression analysis, early postoperative ODI changes were associated with T2 signal (B = -10.22, sig < 0.05), long-term changes were associated with alterations in SR (B = 5.63, sig < 0.05) and SCSA (B = -0.13, sig < 0.05).

Conclusion

The residual mass observed in early postoperative MR images after PELD was the retained annulus fibrosus intraoperatively. Short-term changes in clinical symptoms after PELD were linked to T2 signal intensity, while long-term changes were associated with changes in SR and SCSA.

Comparison of clinical outcomes between unilateral biportal endoscopic discectomy and percutaneous endoscopic interlaminar discectomy for migrated lumbar disc herniation at lower lumbar spine: a retrospective controlled study

BACKGROUND

Both Unilateral Biportal Endoscopic Discectomy (UBED) and Percutaneous Endoscopic Interlaminar Discectomy (PEID) have resulted in favorable clinical outcomes in the management of LDH. The aim of this study is to comprehensively compare the efficacy of UBED and PEID in treating migrated LDH in the lower lumbar spine, with a specific focus on high-grade migrated LDH.

METHODS

96 patients who underwent UBED (31 cases) and PEID (65 cases) procedures were enrolled in the study. All patients received a minimum follow-up period of 6 months. Clinical outcomes of the patients were assessed with incision length, operation time, total hemoglobin loss, hospital stay, intraoperative fluoroscopy times, visual analogue scale (VAS) for lower back and leg pain, Oswestry disability index (ODI), modified MacNab criteria, complications, area of lamina loss and increased intervertebral height.

RESULTS

The VAS scores for lower back and leg pain and ODI significantly decreased in both groups after the operation. Preoperatively, at 1 day, 1 month, and 6 months after the procedure, the VAS and ODI scores exhibited no significant differences between the two groups. There was no significant difference in terms of modified MacNab criteria, area of lamina loss, and increased intervertebral height. The UBED group had a longer incision length, operation time and postoperative hospital stay, and fewer intraoperative fluoroscopy times than to the PEID group. Complications were noted in both groups throughout the follow-up period, but there was no significant difference in the rate of complications. Moreover, there were no notable differences in clinical outcomes between the two groups in the high-grade migrated LDH.

CONCLUSIONS

Both UBED and PEID could achieve favorable clinical outcomes for treating migrated LDH at the lower lumbar spine. Despite the longer operative time and postoperative hospital stay associated with the UBED group, UBED remains safe and innovative for treating migrated LDH at the lower lumbar spine.

Is Full-Endoscopic Transforaminal Lumbar Interbody Fusion Superior to Open Transforaminal Lumbar Interbody Fusion for Single-Level Degenerative Lumbar Spondylolisthesis? A Retrospective Study

BACKGROUND

 In this study, we evaluate the clinical efficacy and safety of full-endoscopic transforaminal lumbar interbody fusion (TLIF) for treatment of single-level lumbar degenerative spondylolisthesis.

METHODS

 Fifty-three patients were divided into two groups according to the surgical techniques: Full endoscopic (Endo)-TLIF (n = 25) and TLIF (n = 28). Clinical efficacy was evaluated pre- and postoperatively. The operation time, operative blood loss, postoperative amount of serum creatine phosphokinase (CPK), postoperative drainage volume, postoperative hospital stay time, total cost, and operative complications were also recorded.

RESULTS

 Compared with the TLIF group, the Endo-TLIF group had similar intraoperative blood loss, less postoperative increased CPK, less postoperative drainage volume, and shorter postoperative hospital stay, but longer operative time and higher total cost. The postoperative visual analog scale (VAS) scores of back and leg pain and Oswestry Disability Index (ODI) scores significantly improved compared with the preoperative scores in both two groups; more significant improvement of postoperative VAS scores of back pain and ODI scores were shown in the Endo-TLIF group at the 1-month follow-up (p < 0.05). No difference was found in the intervertebral fusion rate between the two groups.

CONCLUSION

 The Endo-TLIF has similar clinical effect compared with the TLIF for the treatment of lumbar degenerative spondylolisthesis. It also has many surgical advantages such as less muscle trauma, less postoperative back pain, and fast functional recovery of the patient. However, steep learning curve, longer operative time, and higher total cost may be the disadvantages that limit this technique. Also, the Endo-TLIF treatment of patients with bilateral lateral recess stenosis is considered a relative contraindication.

Feasibility of Endoscopic Lumbar Discectomy in a Remote Government Hospital in Thailand: A Cost-Utility Analysis

BACKGROUND

Treatments for lumbar discectomy have developed over time. Recently, endoscopy has played an important role. However, a major obstacle to endoscopy in rural areas is the cost of surgery, particularly for endoscopes and disposable equipment. We assessed the cost effectiveness of endoscopic lumbar discectomy compared to the traditional open microdiscectomy technique in a government hospital in a developing country.

METHODS

This study focused on 50 patients who underwent endoscopic lumbar discectomy between April 2019 and March 2020 at Yala Regional Hospital and were reviewed by our team. The duration of hospital stays, operative time, follow-up, and clinical outcomes at one, three, and six months postoperatively were observed and compared with 30 patients who underwent microscopic lumbar discectomy. Hospital expenses were calculated and compared using t-tests.

RESULTS

Endoscopic discectomy was 4.00 days length of stay while microscopic discectomy has 9.77 days in averages. The pain score was 8.82 for endoscopic surgery and 9.1 for microscopic surgery. The operative price for the endoscopic discectomy was 144.69 USD higher than that for the open lumbar discectomy because of the disposable equipment. However, each patient in the microdiscectomy group had a longer hospital stay and required more perioperative care, which decreased the difference of the total hospital expenses (1,420.612 vs 1,399.16 USD).

CONCLUSION

Full endoscopic lumbar discectomy is an effective procedure that is beneficial for patients. The total hospital costs are not significantly different between the two procedures. To ensure that more patients receive this benefit and to develop surgical competency in government hospitals, the surgical reimbursement fee for endoscopic discectomy should be more affordable than that for conventional discectomy.

Translaminar Full Endoscopic Technique with Tom Shidi Needles for Highly- and Dorsally-Migrated Lumbar Disc Herniations

BACKGROUND

Thirty years have passed since Kambin's first clinical series of lumbar disc herniations (LDH) treated by arthroscopic microdiscectomy. Despite several advances in this interim, sequestrated LDHs over the dorsal aspect of the dura, and high-grade up- or downward disc migration have been a relative limitation of the transforaminal endoscopic technique. The interlaminar window was the next step to deal with such highly migrated LDHs. Favorable outcomes were obtained in 70-90% of the patients in the long-term, but recurrence rates remained high (approximately 12%), and the approach could be limited by the size of the interlaminar window. Few relevant studies have addressed the role of translaminar full endoscopic technique for migrated LDHs. To describe an innovative modification of the translaminar full endoscopic approach with Tom Shidi needles.

METHODS

This technical modification is presented in a detailed fashion for treating these challenging LDHs and illustrated through a clinical case.

RESULTS

The patient underwent successful translaminar full endoscopic technique with complete pain resolution postoperatively. The postprocedural course was uneventful. A follow-up imaging showed no evidence of residual LDHs fragments.

CONCLUSIONS

Translaminar full endoscopic technique with Tom Shidi needles is a promising modification of the previously presented interlaminar and translaminar endoscopic routes in the treatment of migrated LDHs to fasten surgical procedures and increase the safety of spinal canal manipulation.

Transforaminal Epidural Injection for Far Lateral Lumbar Disc Herniations: An Alternative to Surgery or Just a Delay?

OBJECTIVE

 Far lateral lumbar disc herniations (FLLDH) are known for causing severe and persistent radicular pain due to direct nerve root and dorsal root ganglion compression. This study evaluates the effectiveness of transforaminal epidural steroid injection (TFSI) in patients with FLLDH, assessing its role as a potential alternative to surgery.

METHODS

 The study retrospectively analyzed 42 patients with radicular pain caused by FLDH, confirmed via lumbar magnetic resonance imaging, who had not benefited from conservative treatment. All patients underwent TFSI, and their pre-treatment Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores were compared with scores at one, two, and three months post-procedure.

RESULTS

 The study group comprised 19 males (45.23%) and 23 females (54.77%), with a mean age of 51.9 ± 11.63 years (range 29-76 years). The most common herniation levels were L4-L5 (22 patients), followed by L5-S1 (15 patients) and L3-L4 (five patients). The mean VAS score decreased significantly from 8.58 ± 0.63 to 2.89 ± 1.87 over three months (p = 0.001). Similarly, the mean ODI score significantly reduced from 61.29 ± 6.72 to 16.88 ± 11.25 (p = 0.001). However, eight of the 42 patients (19.04%) underwent surgery within three months due to lack of benefit from TFSI.

CONCLUSION

Our study sheds light on the significant potential of TFSI as a treatment option for FLLDH. The marked improvement in pain and functional capacity, as evidenced by the substantial decrease in VAS and ODI scores, suggests that TFSI can be an effective non-surgical intervention for a majority of patients suffering from FLLDH. However, a notable proportion of patients may still require surgery, indicating that TFSI might not be a definitive alternative but can be an effective interim treatment in managing FLLDH.

Unilateral biportal endoscopic versus uniportal full-endoscopic for lumbar degenerative disease: A meta-analysis

BACKGROUND

Despite the increasing use of unilateral biportal endoscopic (UBE) and uniportal full-endoscopic (UPFE) techniques in lumbar degenerative disease (LDD), few comprehensive and systematic studies have been published comparing UBE and UPFE. Therefore, we conducted a meta-analysis to compare the surgical outcomes of the two procedures.

METHODS

We searched all studies that compared operative outcomes of UBE and UPFE for lumbar disc degeneration disease from PubMed, Google Scholar, Web of Science, Chinese Biomedical Literature Database, China National Knowledge Infrastructure (CNKI), Wanfang and other databases up to March 30, 2022.

RESULTS

This meta-analysis, which included nine articles, showed that in operative time, (mean difference [MD]: 17.14; 95% confidence intervals [CI]: 6.52 to 27.76), intraoperative bleeding (MD: 59.01; 95% CI: 21.29 to 96.73) and hospital stay (MD: 2.12; 95% CI: 0.35 to 3.90), the UPFE group was more advantageous. UBE had an advantage in terms of postoperative dural expansion area (MD: 59.01; 95% CI: 21.29 to 96.73). These aspects included postoperative clinical score (MD: 0.48; 95% CI: -0.27 to 1.24; MD: -0.07; 95% CI: -0.30 to 0.16; MD: 0.09; 95% CI: -0.09 to 0.26; MD: 0.11; 95% CI: -0.04 to 0.26; MD: -0.81; 95% CI: -3.03 to 1.41; MD: -0.38; 95% CI: -1.02 to 0.26), excellent and good rate (odds ratio [OR] = 1.08; 95% CI: 0.34 to 3.44), complications (OR = 0.82; 95% CI: 0.31 to 2.12), postoperative hospital stay (MD: 1.63; 95% CI: -0.81 to 4.07) and mean number of fluoroscopies (MD: -7.18; 95% CI: -22.84 to 8.48), with no significant difference between the two groups. Meanwhile, the lumbar disc herniation (LDH) subgroup of UPFE had a significantly shorter operation time (MD: 31.67; 95% CI: 12.44 to 50.90) than that of UBE.

CONCLUSION

Our study showed that UPFE was associated with shorter operative time, less intraoperative bleeding and shorter hospital stay, whereas UBE was associated with a greater increase in postoperative dural sac area. Postoperative visual analog scale (VAS) scores, Oswestry Disability Index (ODI) scores, satisfaction rates, complications, and mean number of fluoroscopic views were not dramatically dissimilar in UBE and UPFE for LDD. In the LDH subgroup, postoperative hospital stay and operative time were significantly lower in the UPFE group than in the UBE group.

Comparison of percutaneous endoscopic interlaminar discectomy and conventional open lumbar discectomy for L4/5 and L5/S1 double-segmental lumbar disk herniation

OBJECTIVE

Although spinal endoscopic techniques have shown great advantages in the treatment of single-segment lumbar disk herniation (LDH), the therapeutic advantages for double-segment LDH are controversial. To compare the outcomes of percutaneous endoscopic interlaminar discectomy (PEID) versus conventional open lumbar discectomy (COLD) for the treatment of L4/5 and L5/S1 double-segmental LDH.

METHODS

From January 2016 to September 2021, we included 50 patients with double-segmental LDH who underwent PEID (n = 25) or COLD (n = 25). The clinical outcomes between the two groups were evaluated using the visual analog scale (VAS), the Oswestry disability index (ODI), and the modified MacNab criteria. Moreover, the incision length, operation time, intraoperative fluoroscopy time, postoperative bedtime, hospital stays, and complications were also recorded and compared after surgery.

RESULTS

In both groups, the VAS and ODI scores at different timepoints postoperatively were significantly improved compared with those preoperatively (P < 0.05) According to the modified MacNab criteria, the excellent or good outcome rate was 92% in the PEID group and 88% in the COLD group. The PEID group had shorter incision length, postoperative bedtime, and hospital stays than the COLD group. However, the operation time was shorter and intraoperative fluoroscopy time was fewer in the COLD group. In addition, there was no significant difference between the two groups in terms of surgical complications during the postoperative follow-up period.

CONCLUSIONS

Both PEID and COLD have good efficacy and high safety for management of L4/5 and L5/S1 double-segmental LDH. Compared with the COLD group, the PEID group had more operative time as well as more intraoperative fluoroscopy, but it had a more minimally invasive surgical incision as well as faster postoperative recovery.

A 2-Year Outcomes and Complications of Various Techniques of Lumbar Discectomy: A Multicentric Prospective Study

STUDY DESIGN

Prospective Study.

OBJECTIVES

There are numerous techniques for performing lumbar discectomy, each with its own rationale and stated benefits. The authors set out to evaluate and compare the perioperative variables, results, and complications of each treatment in a group of patients provided by ten hospitals and operated on by experienced surgeons.

METHODS

This prospective study comprised of 591 patients operated between February-2017 to February-2019. The procedures included open discectomy, microdiscectomy, tubular microdiscectomy, interlaminar endoscopic lumbar discectomy, transforaminal endoscopic lumbar discectomy and Destandau techniques with a follow-up of minimum 2 years. VAS (Visual Analogue Score) for back and leg pain, ODI (Oswestry Disability Index), duration of surgery, hospital stay, length of scar, operative blood loss and peri-operative complications were recorded in each group.

RESULTS

Post-operatively, there was a significant improvement in the VAS score for back pain as well as leg pain, and ODI scores spanning all groups, with no significant distinction amongst them. When compared to open procedures (open discectomy and microdiscectomy), minimally invasive surgeries (tubular discectomy, interlaminar endoscopic lumbar discectomy, transforaminal endoscopic lumbar discectomy, and Destandau techniques) reported shorter operative time, duration of hospital stays, better cosmesis, and lower blood loss. Overall, the complication rate was reported to be 8.62%. Complication rates differed slightly across approaches.

CONCLUSION

Minimally invasive surgeries have citable advantages over open approaches in terms of perioperative variables. However, all approaches are successful and provide comparable pain relief with similar functional outcomes at long term follow up.

Comparison of 2 Anesthetic Methods for Transforaminal Endoscopic Lumbar Discectomy: A Prospective Randomized Controlled Study

STUDY DESIGN

Randomized controlled trial.

OBJECTIVES

To compare the effect and safety of 2 anesthetic methods using in the operation of Transforaminal Endoscopic Lumbar Discectomy.

METHODS

From the January of 2020 to the December of 2021, 230 consecutive patients that underwent TELD were applied with two methods of anesthesia. All the patients were divided into two groups. The Monitored Anesthesia Care (MAC) group used the local anesthesia (LA) with MAC that based on the combination of dexmedetomidine and butorphanol tartrate. The LA group used the local anesthesia only. Then the Visual Analogic Scale (VAS) through the operating period was compared between the two groups at the time points of before operation (T0), inserting of the puncture needle (T1), establishing of the working cannula (T2), excision of the fibrous rings (T3) and immediately postoperatively (T4). Also, the satisfaction degree of the patients for the course of the operations and the occurrence of the complications were compared between the two groups.

RESULTS

There were no differences of the VAS around the operating area at the time point of T0. Then the MAC group expressed lower scores at all other points of T1, T2, T3 and T4. Then the satisfaction degree of the MAC group was superior than the LA group. No difference was observed for the occurrence of the complications.

CONCLUSIONS

MAC based on the combination of dexmedetomidine and butorphanol tartrate is an ideal method of anesthesia for TELD with enough effect and safety.

Retrospective Study of Minimal Three-Year Follow-Up of Transforaminal Endoscopic Discectomy for Lumbar Disc Herniation: 5000 Multicenter Cases

Objective The objective of this study was to investigate the long-term effects of percutaneous transforaminal endoscopic lumbar discectomy (PTELD) and clarify the differences between outside-in and inside-out techniques. Methodology This was a multicenter retrospective study with a chart review of questionnaires about patients' quality of life. Patients were recruited from three hospitals in China. Based on certain inclusion and exclusion criteria, we enrolled in the study 5000 patients aged ≥18 years diagnosed with lumbar disc herniation who received PTELD from September 2015 to September 2019. The outside-in technique (n=2039) was compared with the inside-out technique for PTELD (n=1890) on the Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and the Short Form 36 (SF-36) of the Health Survey Questionnaire (physical component) both pre-operatively and post-operatively. Results VAS, ODI, and SF-36 significantly improved just after surgery for both techniques compared with pre-operative status. Nevertheless, significant differences existed between the two techniques concerning VAS for leg pain, VAS for back pain, ODI, and SF-36 at 0.5 months post-operatively. The above indices steadily improved within six months after both techniques, after which they did not significantly improve. In detail, outside-in patients suffered more back pain and worse ODI and SF-36 (physical) but had more relief from leg pain 0.5 months after surgery in terms of VAS. As for recovery rate from symptoms, there were only significant differences in recovery rate for leg pain and back pain at the first 1.5 months post-operatively. As for satisfaction rates, the outside-in technique had better results than the inside-out technique at both 0.5 months and 12 months. Conclusion Both techniques could relieve the symptoms of lumbar disc herniation. However, patients in the outside-in group suffered more back pain and a bigger risk of nerve injury than those in the inside-out group.

Percutaneous Radiofrequency Disc Decompression: A Study of 27 Patients

BACKGROUND

Percutaneous radiofrequency nucleoplasty is a true minimally invasive technique for treatment for radiculopathy caused by contained disc protrusions. This minimally invasive procedure uses controlled thermoablation for reducing the intervertebral disc and decompressing the lumbar nerve root. Material and Methods: Our study is a prospective analysis of 27 patients aged from 30 to 64 years with lumbar disc protrusion who were treated with percutaneous radiofrequency disc decompression (PRFD) between May 2018 and May 2019. Clinical follow-up was reported at 1 month, 3 months, and 6 months. The outcomes were assessed using a visual analog scale (VAS) and MacNab score.

RESULTS

Of the 27 patients, 14 were female and 13 were male. Their mean age was 53 ± 2 years. In all 27 patients, percutaneous radiofrequency nucleotomy was performed. An excellent outcome as reflected by MacNab score was observed in 17 patients (63%), a good outcome in 8 patients (29.7%), and a poor outcome in 2 patients (7.3%). Prior to treatment, the average back and leg VAS scores were 7.95 and 7.82, respectively. At sixth month follow-up, the back and leg VAS scores were reduced to 3.17 and 3.04, respectively. Patients with a poor outcome developed early recurrent disc prolapse and required endoscopic discectomy.

CONCLUSION

PRFD is a safe and effective treatment of contained disc protrusion. PRFD is a good alternative to surgery. These procedures significantly increase quality of life in patients with lumbar radiculopathy.

Future of Endoscopic Spine Surgery: Insights from Cutting-Edge Technology in the Industrial Field

In the evolving landscape of spinal surgery, technological advancements play a pivotal role in enhancing surgical outcomes and patient experiences. This paper delves into the cutting-edge technologies underpinning endoscopic spine surgery (ESS), specifically highlighting the innovations in scope cameras, RF equipment, and drills. The modern scope camera, with its capability for high-resolution imaging, offers surgeons unparalleled visualization, enabling precise interventions. Radiofrequency (RF) equipment has emerged as a crucial tool, providing efficient energy delivery for tissue modulation without significant collateral damage. Drills, with their enhanced torque and adaptability, allow for meticulous bone work, ensuring structural integrity. As minimally invasive spine surgery (MISS) becomes the standard, the integration and optimization of these technologies are paramount. This review captures the current state of these tools and anticipates their continued evolution, setting the stage for the next frontier in spinal surgery.

Functional Outcomes After Discectomy for Recurrent Lumbar Herniation Using the Destandau Endospine System: A Retrospective Study of 44 Patients

Background Recurrent disc herniation is a major cause of morbidity and surgical failure after disc surgery. This study aimed to investigate the feasibility, safety, and effectiveness of the Destandau endospine system (DES) for treating recurrent lumbar disc herniation (LDH). Methodology A total of 44 patients who underwent minimally invasive Destandau endoscopic lumbar discectomy (DELD) for recurrent LDH were included in this study. All data were collected retrospectively. The preoperative and postoperative visual analog scale (VAS) score was used for the evaluation and gradation of pain. The clinical outcome was analyzed according to modified MacNab criteria. The minimum follow-up was two years. Preoperative and postoperative VAS scores were compared using the paired Student's t-test. Statistical significance was set at a p-value <0.05. Results The mean surgical time was 30 ± 20 minutes. The VAS score for leg pain was improved in all cases from 5.9 ± 2.1 to 1.7 ± 1.3 (p< 0.001). In 98% of cases, a successful outcome was noted (excellent or good outcome according to MacNab criteria). In three (7%) patients, incidental durotomy occurred, but there was no neurological worsening, cerebrospinal fluid fistula, or negative influence on the clinical outcome. No recurrence or instability occurred in our series. Conclusions The clinical outcomes of minimally invasive DES for LDH were found to be comparable with the reported success rates of other minimally invasive techniques reported in the existing literature. The dural tear rate was independent of postoperative morbidity and functional outcome. The technique is a safe and effective treatment option for recurrent LDH.

Comparative analysis of patient-reported outcomes after percutaneous endoscopic lumbar discectomy between transforaminal and interlaminar approach: a minimum two year follow-up

PURPOSE

Percutaneous endoscopic lumbar discectomy has been increasingly used in the treatment of lumbar disc herniation. However, there is no consensus on which method would be more effective between the transforaminal and interlaminar approach.

OBJECTIVE

To compare clinical outcomes, patient satisfaction rate, reoperation rate, and residual symptoms between percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID).

STUDY DESIGN

A comparative, retrospective, controlled trial.

SETTING

The study was conducted at the Department of Orthopaedics at a local hospital.

METHODS

From January 2015 to September 2020, consecutive patients who underwent PETD or PEID treatment for lumbar disk herniation (LDH) at the L5/S1 level in our department were retrospectively collected. Baseline data including age, gender, body mass index (BMI), smoking status, alcohol drinking, clinical symptoms, physical examination, and radiographic characteristics were documented. During the two to three year follow-up periods, patients were evaluated clinically, including clinical outcomes assessed by the visual analog score (VAS), patient satisfaction rates assessed by the North American Spine Society patient satisfaction index (PSI), recurrent rate, and residual symptoms.

RESULTS

A total of 113 patients with PELD in our department were included in the current study, with 65 patients in the PETD group and 48 in the PEID group. Demographic characteristics including age, gender, height, BMI, cigarette smoking, alcohol consumption status, and diabetes did not show any significant difference between the PETD and PEID groups. The VAS scores of the two groups were similar preoperatively, but the postoperative VAS score of the PEID group was lower than that of the PETD group. There were 90.8% of patients in the PETD group who were satisfied with the operation compared to 97.9% in the PEID group. The recurrence rate did not differ between groups, with three patients in both groups. Regarding residual symptoms, there were more patients in the PETD group who reported low back pain during the follow-up periods.

LIMITATION

The main limitations are that all patients were operated by the same surgical team from the same site, and there was a lack of multicenter data.

CONCLUSION

Both PETD and PEID have satisfactory patient-reported outcomes for treating LDH. The PEID procedure results in fewer low back pain residual symptoms than the PELD procedure.

Transforaminal Endoscopic Lumbar Diskectomy versus Open Microdiskectomy for Symptomatic Lumbar Disk Herniation: A Comparative Cohort Study on Costs and Long-Term Outcomes

BACKGROUND

 Transforaminal endoscopic lumbar diskectomy (TELD) is considered an effective treatment for lumbar disk herniation (LDH). There is a paucity of studies comparing in detail the costs and long-term clinical outcomes of TELD and open microdiskectomy (MD), especially in developing countries. Thus, we sought to provide a multidimensional insight into this matter by comparing the direct costs and long-term outcomes of TELD with those of MD.

METHODS

 The electronic health records of 434 patients with LDH who underwent either TELD or MD were collected from February 2011 to October 2014. Within a 7-year follow-up period, 412 patients, comprising 203 patients treated with TELD and 209 patients treated with MD, were fully evaluated. Patient characteristics, operative time, intraoperative blood loss (IBL), postoperative hospital stay, time to return to work (RTW), perioperative complications, and direct costs were collected. Clinical outcomes were assessed using the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and modified MacNab criteria.

RESULTS

 The postoperative ODI and VAS scores improved significantly in both groups (p < 0.001). In accordance with the modified MacNab criteria, the rate of excellent and good outcomes was 88.67 and 88.03% in the TELD and MD groups, respectively. There were no significant differences between the groups in the clinical outcomes and perioperative complications. However, IBL, hospital stay, and RTW were significantly reduced in the TELD group (p < 0.05). Twenty-one cases in the TELD group and nine in the MD group underwent reoperation due to recurrence (p < 0.05). Total inpatient cost per patient was $1,596 in the TELD group and $1,990 in the MD group (p < 0.05).

CONCLUSION

 TELD for the treatment of symptomatic LDH could be an affordable strategy, providing certain advantages of minimally invasive procedures such as shorter hospital stay and earlier recovery along with comparable clinical outcomes to the conventional surgical method.

Surgical Technique of Central and Over-the-Top Full-Endoscopic Decompression of the Cervical Spine: A Technical Note

Endoscopic surgery of the cervical spine is constantly evolving and the spectrum of its indications has expanded in recent decades. Full-endoscopic techniques have standardized the procedures for posterior and anterior access. The full-endoscopic approach was developed to treat degenerative diseases with the least possible invasion and without causing instability of the cervical spine. The posterior full-endoscopic approach is indicated for the treatment of diseases of the lateral part of the vertebral segment, such as herniations and stenoses of the lateral recess and vertebral foramen. There has been little discussion of this approach to the treatment of central stenosis of the cervical spine. This technical note describes a step-by-step surgical technique for central and over-the-top full-endoscopic decompression in the cervical spine, using a 3.7 mm working channel endoscope. This technique has already been shown to be effective in a recent case series with a 4.7 mm working channel endoscope, and may represent a new treatment option for central or bilateral lateral recess stenosis. There is also the possibility of a bilateral full-endoscopic approach, but this may be associated with greater muscle damage and a longer operative time. Case series and comparative studies should be encouraged to confirm the safety and utility of this technique.

Research Trends of Percutaneous Endoscopic Lumbar Discectomy in the Treatment of Lumbar Disc Herniation Over the Past Decade: A Bibliometric Analysis

Objective

This study aimed to explore the research trends of percutaneous endoscopic lumbar discectomy in treating lumbar disc herniation using bibliometrics over the past ten years.

Methods

Relevant publications on the clinical application of percutaneous endoscopic lumbar discectomy in lumbar disc herniation were searched in the Web of Science Core Collection. Subsequently, the characteristics of all these articles were collected. Visualizing data of annual publications, journals, cited journals, authors, cited authors, countries, institutions, keywords, and cited references was performed by using CiteSpace (6.1.R6).

Results

A total of 642 publications were extracted between 2013 and 2022. The number of publications peaked in the year 2020. The most prolific journal was World Neurosurgery (81), and Spine (597) as the cited journal was the most popular one. China (393) was the most prolific country, followed by South Korea (100). The institution with the most productivity was Tongji University (35). Yue Zhou (20) was the most prolific author, and Sebastian Ruetten (310) was the most cited author. The keyword "interlaminar" was top of research developments with the highest citation burst (8.69). "Lumbar disc herniation", "surgical technique", and "complication" were popular keywords. The surgical procedures and complications of percutaneous endoscopic lumbar discectomy have been the hot topics of recent research.

Conclusion

This study summarized the current situation and development trends of percutaneous endoscopic lumbar discectomy clinical research in the form of visualization, and these findings may help researchers explore new directions in the future.

Surgical Strategy and Outcomes of Full Endoscopic Lumbar Discectomy for Recurrent Lumbar Disk Herniation Following a Previous Full Endoscopic Lumbar Discectomy

OBJECTIVE

Recurrent lumbar disc herniation (RLDH) cannot be prevented after full endoscopic lumbar discectomy (FELD), and the optimal surgical treatment for RLDH after FELD remains controversial. The aim of the study was to suggest a surgical strategy for FELD to treat RLDH following a previous FELD and to present surgical outcomes.

METHODS

Between February 2015 and March 2022, 68 patients with RLDH were surgically treated with FELD retrospectively. An original approach was suggested for the treatment of early recurrence (24 h-2 weeks). The full endoscopic transforaminal technique (FETD) was considered for patients requiring local anesthesia, and in RLDH with FETD indications or FEID technological difficulties. The full endoscopic interlaminar technique (FEID) was chosen in RLDH with FEID indications. Both FEID and FETD were suitable if no FEID or FETD technological difficulties existed. Clinical efficacy was evaluated using the visual analog scale (VAS) score, Oswestry disability index (ODI), and modified MacNab criteria. Postoperative follow-up data at 24 h, 3 months, and final-follow-up were recorded. Operation time and clinical outcomes were assessed with t test. p-value < 0.05 was considered statistically significant.

RESULTS

All 68 patients had an average follow-up time of 23.8 months (range, 6-76 months). In the 13 cases of early recurrence, the operation time (32.30 ± 9.67 vs. 58.00 ± 6.16 min) in the original surgical approach group was shorter than that in the changing surgical approach group (p < 0.05). In the 28 cases of L4/5 FETD recurrence (>2 weeks), the operation time (66.17 ± 12.18 vs. 53.60 ± 5.45 min) in the FETD group was more than that in the FEID group (p < 0.05). In the 22 cases of L5S1 recurrence (>2 weeks), the operation time (55.75 ± 8.79 vs. 79.33 ± 6.65 min) in the FEID group was shorter than in the FETD group (p < 0.05). The postoperative VAS and ODI scores at 24 h, 3 months, and final-follow up were all significantly improved, compared with their preoperative counterparts (p < 0.05). Based on the modified MacNab criteria, 88.23% of patients showed excellent or good results. Re-recurrence occurred in three patients at 3 months. No surgical complications were observed in any of the 68 cases.

CONCLUSION

FELD is a safe and effective treatment option for RLDH with previous FELD. For early recurrence, the original approach was suggested. Both FEID and FETD were effective and safe for recurrence (>2 weeks), but FEID seemed more efficient for L4/5 RLDH after previous FETD and for L5S1 RLDH.

Long-Term Radiographic and Clinical Outcomes in Patients Undergoing Transforaminal Endoscopic Lumbar Discectomy: A Propensity Score Matching Study

Background

Our study aims to investigate the long-term clinical and radiographic effects of transforaminal endoscopic lumbar discectomy (TELD) on lumbar disc herniation.

Patients and Methods

Radiographic and clinical data of patients undergoing TELD in our institution from January 2015 to January 2019 were retrospectively collected. LDH outpatients who had not received surgical treatment during the same period were 1:1 matched by propensity score matching as the conservative group. The radiographic parameters of the two groups at baseline and at the last follow-up (≥24 months) were analyzed.

Results

The study included 47 patients in the TELD group, matched with 47 patients in the conservative group. The disc height of the TELD group at the last follow-up was lower than that at the baseline (P < 0.001), and lower than that of the conservative group at the last follow-up (P < 0.05). The disc degeneration grade of the TELD group at the last follow-up was greater than that at the baseline, and greater than that of the conservative group at the last follow-up. There was no significant difference in the facet joint degeneration in the TELD group between the baseline and the last follow-up, and between the TELD group and the conservative group at the last follow-up (P > 0.05). The pain intensity and disability score in the TELD group at 3-month follow-up and at the last follow-up were significantly lower than those at the baseline (P < 0.001). Six patients in the TELD group required additional surgery during the follow-up period.

Conclusion

Our long-term follow-up data shows that the disc height of the operated level was significantly reduced and the disc degeneration was significantly aggravated in TELD-treated patients; in contrast, the facet joint degeneration did not show significant aggravation.

Anesthesia methods for full-endoscopic lumbar discectomy: a review

Full-endoscopic lumbar discectomy under local anesthesia is major trends for the treatment of lumbar disc herniation in spine minimally invasive surgery. However, sometimes local anesthesia is not enough for analgesic in surgery especially in interlaminar approach. This study summarizes the current study of anesthesia methods in full-endoscopic lumbar discectomy. Local anesthesia is still the most common anesthesia method in full-endoscopic lumbar discectomy and the comparison group for other anesthesia methods due to high safety. Compared to local anesthesia, Epidural anesthesia is less applied in full-endoscopic lumbar discectomy but reports better intraoperative pain control and equivalent safety due to the motor preservation and pain block characteristic of ropivacaine. General anesthesia can achieve totally pain block during surgery but nerve injury can not be ignored, and intraoperative neuromonitoring can assist. Regional anesthesia application is rare but also reports better anesthesia effects during surgery and equivalent safety. Anesthesia methods for full-endoscopic lumbar discectomy should be based on patient factors, surgical factors, and anesthesiologist factors to achieve satisfactory anesthesia experience and successful surgery.

Unilateral Bi/Multi-Portal Endoscopy for the Treatment of Complicated Lumbar Degenerative Diseases with Utilization of Uniaxial Spinal Endoscope, Instead of Arthroscope: Technique Note and Clinical Results

Objective

This article aims to discuss a novel surgical strategy, referred to as unilateral bi/multi-portal endoscopy (UME), which used a uniaxial spinal endoscope instead of an arthroscope in the traditional unilateral biportal endoscopy (UBE) surgical procedure in our study of the treatment of complicated lumbar degenerative diseases.

Methods

This retrospective study included 42 patients diagnosed with high-migrated lumbar disc herniation and bilateral spinal stenosis who underwent UME surgery from January 2021 to December 2021. Patients included 20 men and 22 women, with an average age of 55.97±14.92 years. The average follow-up period was 13.19 months. The demographic data, operation time (min), and complications were recorded and analyzed. The visual analogue scale (VAS), Oswestry Disability Index (ODI) scores were used to evaluate the surgical outcomes. Three-dimensional CT scans and MRI were conducted to evaluate the radiographic improvement.

Results

A total of 26 patients were diagnosed with lumbar disc herniation and 16 with lumbar spinal stenosis. All 42 patients underwent UME surgery and achieved satisfactory outcomes. The operation time was 154.46±46.09 min. The average follow-up time was 13.19±1.33 months. The preoperative back pain (VAS-Back) and the last follow-up VAS-Back were 3.84±1.00 and 0.70±0.46, respectively (P < 0.05). The preoperative leg pain (VAS-Leg) and the last follow-up VAS-Leg were 6.46±1.08 and 1.03±0.64, respectively (P <0.05). Significant differences existed between preoperative ODI scores (58.70±11.22%) and the last follow-up ODI scores (9.24±3.04%; P<0.05). All patients achieved significant pain relief and functional improvement after the surgery. No severe complications occurred, except for two cases of postoperative dysesthesia and one case suffered from vertebral compression fractures induced by a postoperative accidental injury. Symptoms of numbness disappeared within one week with treatment using dexamethasone and neurotrophic drugs. The vertebral fracture case recovered with percutaneous kyphoplasty treatment.

Conclusion

This study suggests that UME is a promising treatment strategy for high-migrated disc herniation and bilateral spinal stenosis.

Minimally invasive endoscopy in spine surgery: where are we now?

INTRODUCTION

Endoscopic spine surgery (ESS) is a minimally invasive surgical technique that offers comparable efficacy and safety with less collateral damage compared to conventional surgery. To achieve clinical success, it is imperative to stay abreast of technological advancements, modern surgical instruments and technique, and updated evidence.

PURPOSES

To provide a comprehensive review and updates of ESS including the nomenclature, technical evolution, bibliometric analysis of evidence, recent changes in the spine communities, the prevailing of biportal endoscopy, and the future of endoscopic spine surgery.

METHODS

We conducted a comprehensive review of the literature on ESS for the mentioned topics from January 1989 to November 2022. Three major electronic databases were searched, including MEDLINE, Scopus, and Embase. Covidence Systematic Review was used to organize the eligible records. Two independent reviewers screened the articles for relevance.

RESULTS

In total, 312 articles were finally included for review. We found various use of nomenclatures in the field of ESS publication. To address this issue, we proposed the use of distinct terms to describe the biportal and uniportal techniques, as well as their specific approaches. In the realm of technical advancement, ESS has rapidly evolved from addressing disc herniation and spinal stenosis to encompassing endoscopic fusion, along with technological innovations such as navigation, robotics, and augmented reality. According to bibliometric analysis, China, South Korea, and the USA have accounted for almost three-quarters of total publications. The studies of the biportal endoscopy are becoming increasingly popular in South Korea where the top ten most-cited articles have been published. The biportal endoscopy technique is relatively simple to adopt, as it relies on a more familiar approach, requires less expensive instruments, has a shorter learning curve, and is also well-suited for interbody fusion. The uniportal approach provided the smallest area of soft tissue dissection. While robotics and augmented reality in ESS are not widely embraced, the use of navigation in ESS is expected to become more streamlined, particularly with the emergence of recent electromagnetic-based navigation technologies.

CONCLUSIONS

In this paper, we provide a comprehensive overview of the evolution of ESS, as well as an updated summary of current trends in the field, including the biportal and uniportal approaches. Additionally, we summarize the nomenclature used in ESS, present a bibliometric analysis of the field, and discuss future directions for the advancement of the field.

Full-endoscopic anterior excision of thoracic disc herniations, including giant and calcified discs with spinal cord compression: surgical technique and outcomes

PURPOSE

Operations on thoracic herniated discs are comparatively rare and often demanding. An individual approach and mastery of different surgical techniques and surgical approaches are necessary. The main factors for the chosen surgical technique and approach are the anatomical localization, consistency of the pathology, the general condition of the patient and the experience of the surgeon. The purpose of this study was to evaluate the technical possibilities and outcomes of the full-endoscopic technique with interlaminar, extraforaminal and transthoracic retropleural approaches in patients with symptomatic herniated discs with anterior neural compression.

METHODS

In 49 patients with thoracic disc herniations, decompression was performed between 2016 and 2020, using a full-endoscopic interlaminar, extraforaminal or transthoracic retropleural approach. Clinical data and imaging were collected during follow-up of 18 months.

RESULTS

Sufficient decompression was achieved in all cases with the full-endoscopic surgical technique. Two patients experienced worsening of myelopathy, one of which was of transient duration, and one patient required reoperation for an epidural hematoma. No other complications were recorded. All other patients experienced a regression or improvement of symptoms.

CONCLUSION

The full-endoscopic technique with interlaminar, extraforaminal or transthoracic retropleural approach is a sufficient and minimally invasive method. All three full-endoscopic approaches of the thoracic spine are required to enable sufficient decompression of the anterior pathologies examined here.

2nd and 3rd generation full endoscopic lumbar spine surgery: clinical safety and learning curve

AIM

2nd and 3rd generation endoscopic spine surgery techniques offer visualisation of familiar inter-laminar anatomy to spinal surgeons. We have prospectively evaluated the clinical outcome, complications and learning curve associated with these techniques in patients with lumbar spine radiculopathy.

METHODS

This is a prospective study of 50 consecutive patients with radicular pain from disc herniation and/or lateral recess stenosis. In 6 patients, endoscopy couldn't be done. Operating times, PROM's (VAS, ODI and EQ-5D scores) and complication rates of 44 patients were evaluated after mean FU of 52 months (range 39-65). MRI was used to divide these into protrusions (n = 19), extrusions (n = 17) and lateral recess stenosis (n = 8). Evidence about the learning curve was gathered by curvilinear regression analyses.

RESULTS

Using a composite clinical success criterion, 95% patients had a successful outcome, with no major complications. ODI, VAS and EQ-5D scores had a statistically significant improvement and achieved MCID. Revision discectomy rate was only 4.5% (n = 2). MRI based grouping, case sequence and degree of difficulty influenced the duration of surgery and a learning curve was found for protrusions and lateral recess decompressions, but not for extrusions. A learning curve effect was also observed with respect to the ODI.

CONCLUSIONS

Although anatomy visualised in 2nd and 3rd generation endoscopy is familiar to spinal surgeons, our learning curve experience suggests a careful and MRI pathology based take up of this technique in clinical practice, despite its clinical safety in our series.

LEVEL OF EVIDENCE

Level 3, prospective cohort study.

Propensity matched outcome analysis following microdiscectomy versus interlaminar endoscopic discectomy for L5-S1 disc herniation

Purpose

The main purpose of the study is to perform a propensity-matched functional outcome analysis following microdiscectomy (MD) versus interlaminar endoscopic lumbar discectomy (IELD) for L5-S1 disc herniation. Although many studies have compared endoscopic lumbar discectomy and microdiscectomy, few have compared the outcomes of microdiscectomy (MD) and interlaminar endoscopic discectomy (IELD) at the L5-S1 level.

Methods

This is a propensity-matched analysis of 100 patients (50 MD patients, 50 IELD patients) based on baseline covariates with a minimum of one-year follow-up. Patient-reported outcome measures were obtained from EMR during follow-up visits. Back pain and sciatic pain were assessed by the Visual Analogue Scale (VAS-B and VAS-L). Functional outcome was assessed using Oswestry Disability Index (ODI) Score and 12-item Short Form Survey (SF-12) score. Data were obtained at baseline (pre-op) and at 0, 1, 3, and 12 months post-operatively.

Results

Mean operative time was significantly lower (p < 0.001) in the IELD group (44 min) compared to the MD group (59 min). Mean VAS-B at the immediate and 1-month postoperative period was significantly (p < 0.001) lower in the IELD group (0.36, 0.24) when compared with the MD group (1.74, 1.16). There was no significant difference between IELD and MD groups with regard to improvement in sciatic pain (VAS-L). ODI scores at 1 month and 3 months post-operative period were significantly (p < 0.001) lower in the IELD group (30.1, 23.2) when compared with the MD group (41, 27.5). However, there was no significant difference between the two groups with regards to VAS-B, ODI, and SF-12 at 1-year follow-up.

Conclusion

Our findings indicate that the IELD group achieved better immediate and early postoperative outcomes despite no significant difference at one-year follow-up.

A Trans-pedicle Approach to Avoid Exiting Nerve Root Injury in Full-Endoscopic Transforaminal Decompression: A Case Report

This report aims to describe a case with an extremely low-located exiting nerve root and introduce the trans-pedicle approach for endoscopic transforaminal decompression, which can enable the safe visualization of the exiting nerve root. We present the medical history, imaging findings, and surgical procedures of a 62-year-old male who underwent left L3/4 and L4/5 endoscopic transforaminal decompression for foraminal stenosis. The patient presented with pain and numbness in the anterior and lateral aspects of the left thigh. MRI revealed left L3/4 and L4/5 foramen stenosis and endoscopic transforaminal decompression was performed. The working channel was guided and positioned at the upper lateral part of the left L4 pedicle. We observed the L3 root being compressed by scar tissues against the upper edge of the L4 pedicle. Then we used a protective diamond burr to drill the upper part of the L4 pedicle, enlarging the L3/4 foramen. Subsequently, pituitary Rongeur, Kerrison, and punches were employed to meticulously remove scar tissues around the exiting root. The same procedure was performed for left L4-5 foramen decompression. The radicular symptoms were relieved immediately after the surgery. Our proposed trans-pedicle endoscopic transforaminal approach can reduce the risk of injuring a low-located exiting nerve root. It can also help standardize the procedure, improves working channel stability, and facilitates the learning process, making it a valuable technique for full-endoscopic transforaminal decompression.

General vs Local Anesthesia for Percutaneous Endoscopic Lumbar Discectomy (PELD): A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review.

OBJECTIVES

It remains unknown whether general anesthesia (GA) or local ± epidural anesthesia (LA) results in superior outcomes with percutaneous endoscopic lumbar discectomy (PELD). The present study sought to examine the impact of anesthesia type on patient-reported outcomes (PROs) and complications with PELD.

METHODS

Systematic review and meta-analysis examining PELD performed under GA or LA was conducted. Patient-reported outcomes including Visual Analog Scale (VAS)-leg/back, and Oswestry Disability Index (ODI) scores were collected. Complication, recurrent disc herniation, durotomy, and reoperation rates as well as surgical data were recorded. All outcomes were compared between pooled studies examining GA or LA.

RESULTS

Sixty-eight studies consisting of 5269 patients (724 GA, 4465 LA) were included in the meta-analysis. Overall complication rate was significantly higher in the GA group (9% vs 4%, P = .003). Durotomy rates, length of stay, recurrent disc herniation and reoperation rates were similar between groups. At the first follow-up timepoint, the LA group demonstrated significant improvements in VAS back and ODI scores (P < .05) while the GA group did not (P > .05). At the final follow-up (> 6 months), the percent of patients achieving an excellent McNab score was significantly higher in the GA vs LA group (P < .001).

CONCLUSIONS

Percutaneous endoscopic lumbar discectomy with LA may be associated with greater short-term improvement in VAS back pain and ODI scores. General anesthesia may be associated with more durable pain relief but a higher complication rate. Further systematic investigation is necessary to determine what short and long term benefits are associated with PELD performed under LA and GA.

Minimally Neural Retractive, Total Annular Resection, Transforaminal Endoscopic (TARTE) Approach for Severely Canal Compromising Lumbar Disk Herniation Accompanied by a Neurologic Deficit

OBJECTIVE

 Treatment of severely canal compromising lumbar disk herniations (LDH), occupying more than 50% of the canal area, are associated with technical difficulty and worse outcomes. This study aimed to describe new techniques of transforaminal endoscopic lumbar diskectomy (TELD) with less neural retraction, and total annular resection for broad-based severely canal compromising disk herniation. We also evaluated the feasibility and safety of the techniques, and analyzed the clinical and radiologic outcomes of 32 patients presenting with neurologic deficits.

METHODS

 A retrospective cohort study was performed with 32 consecutive patients who underwent TELD for broad-based severely canal compromising LDH between January 2018 and January 2020. We removed the LDH using two novel techniques: (1) the "mobile outside-in" approach and total annular resection method and (2) internal decompression and subsequent pushdown method of the migrated fragment. The cross-sectional area (CSA) on magnetic resonance image was evaluated preoperatively and compared with the postoperative image within 7 days and between 6 months and 1 year. The visual analog scale (VAS) for back and leg pain, Oswestry disability index (ODI), MacNab's criteria, and motor power of the involved lower extremities were evaluated pre- and postoperatively.

RESULTS

 A total of 32 patients, with an average age of 37.5 years (range: 17-66), underwent surgery. The mean VAS score for back pain improved from 7.84 ± 1.02 to 1.31 ± 0.54 and the ODI score improved from 74.3 ± 7.82 to 20.4 ± 3.71 at final follow-up. According to MacNab's criteria, 23 patients had excellent and 9 patients had good outcomes at final follow-up. All patients operated on at the L4-L5 level had great toe/ankle dorsiflexion and/or ankle plantar flexion weakness; knee extension weakness was found at the L2-L3 and L3-L4 levels. Motor function improved significantly; the mean values and range preoperatively, and at 1 month, 3 months, and final follow-up, were 3.41 ± 0.95 (1-4), 4.56 ± 0.56 (3-5), 4.88 ± 0.34 (4-5), and 4.97 ± 0.18 (4-5), respectively (p < 0.001, at all follow-up). The mean values and range of the preserved CSA proportion, preoperatively and within 1 week after surgery, and at final follow-up were 34.9 ± 10.9 (15-61), 81.06 ± 10.24 (63-97), and 93.03 ± 5.37 (76-99), respectively (p < 0.001, at all follow-up).

CONCLUSION

 The transforaminal endoscopic approach for broad-based severely canal compromising LDH can be considered a feasible surgical option for an experienced surgeon. With total annular resection and pushdown of migrated fragments, safe and complete removal of LDH was possible in patients with a neurologic deficit. Total annular resection may increase the overall but not the early recurrence rate.

Development of an Endoscopic Spine Surgery Program: Overview and Basic Considerations for Implementation

Endoscopic spine surgery (ESS) is an innovative technique allowing for minimally invasive, direct visualization of spinal abnormalities. The growth of ESS in the United States has been stunted by high start-up costs, low reimbursement rates, and the steep learning curve associated with mastering endoscopic techniques. Hergrae, we describe the current state and future direction of ESS and provide key action items for ESS program implementation.

Comparative Analysis of Non-Full and Full Endoscopic Spine Technique via Interlaminar Approach for the Treatment of Degenerative Lumbar Spinal Stenosis: A Retrospective, Single Institute, Propensity Score-Matched Study

STUDY DESIGN

Retrospective study.

OBJECTIVE

To compare the clinical efficacy of posterior lumbar laminectomy decompression under full endoscopic technique (Endo-LOVE) and percutaneous endoscopic medial foraminal decompression (PE-MFD) in the treatment of degenerative lumbar spinal stenosis (DLSS).

METHODS

Between April 2017 and April 2018, 96 patients with DLSS underwent Endo-LOVE or PE-MFD, including 58 with Endo-LOVE and 38 with PE-MFD. After propensity score matching (PSM), patient characteristics, operation time, intraoperative fluoroscopy times, postoperative bedridden time, hospital stay and postoperative complications were recorded and compared. The clinical efficacy was evaluated according to Oswestry disability index (ODI), visual analogue scale (VAS), lumbar disease JOA and modified MacNab criteria.

RESULTS

A total of 96 patients with DLSS were included in the study. After PSM, the 2 groups were comparable in patient demographic and baseline characteristics. The operation time and intraoperative fluoroscopy times in PE-MFD group were significantly more than those in Endo-LOVE group (P < .05). The operation time in PE-MFD group was significantly less than that in Endo-LOVE group (P < .05).The intraoperative fluoroscopy times in PE-MFD group were significantly more than that in Endo-LOVE group (P < .05). The ODI, VAS and lumbar disease JOA in the 2 groups were significantly improved comparing with those before operation (P < .05). According to the modified MacNab criteria, the excellent and good rates of the 2 groups were 93.5% in Endo-LOVE group and 87.1% in PE-MFD group (P > .05).

CONCLUSION

Endo-LOVE and PE-MFD technique can both effectively treat DLSS, and the short-term follow-up results are positive. Endo-LOVE technique has the advantages of fast puncture positioning, less radiation exposure and wider indications. However, PE-MFD needs more radiation exposure and has the possibility of incomplete decompression for complex multiplanar spinal stenosis.

Risk factors for lumbar disc herniation recurrence after percutaneous endoscopic lumbar discectomy: a meta-analysis of 58 cohort studies

Recurrent lumbar disc herniation (rLDH) is one of the most serious complications and major causes of surgical failure and paralysis following percutaneous endoscopic lumbar discectomy (PELD). There are reports in the literature on the identification of risk factors associated with rLDH; however, the results are controversial. Therefore, we conducted a meta-analysis to identify risk factors for rLDH among patients following spinal surgery. PubMed, EMBASE, and the Cochrane Library were searched without language restrictions from inception to April 2018 for studies reporting risk factors for LDH recurrence after PELD. MOOSE guidelines were followed in this meta-analysis. We used a random effects model to aggregate odds ratios (ORs) with 95% confidence intervals (CIs). The evidence of observational studies was classified into high quality (class I), medium quality (class II/III), and low quality (class IV) based on the P value of the total sample size and heterogeneity between studies. Fifty-eight studies were identified with a mean follow-up of 38.8 months. Studies with high-quality (class I) evidence showed that postoperative LDH recurrence after PELD was significantly correlated with diabetes (OR, 1.64; 95% CI, 1.14 to 2.31), the protrusion type LDH (OR, 1.62; 95% CI, 1.02 to 2.61), and less experienced surgeons (OR, 1.54; 95% CI, 1.10 to 2.16). Studies with medium-quality (class II or III) evidence showed that postoperative LDH recurrence was significantly correlated with advanced age (OR, 1.11; 95% CI, 1.05 to 1.19), Modic changes (OR, 2.23; 95% CI, 1.53 to 2.29), smoking (OR, 1.31; 95% CI, 1.00 to 1.71), no college education (OR, 1.56; 95% CI, 1.05 to 2.31), obesity (BMI ≥ 25 kg/m²) (OR, 1.66; 95% CI, 1.11 to 2.47), and inappropriate manual labor (OR, 2.18; 95% CI, 1.33 to 3.59). Based on the current literature, eight patient-related and one surgery-related risk factor are predictors of postoperative LDH recurrence after PELD. These findings may help clinicians raise awareness of early intervention for patients at high risk of LDH recurrence after PELD.

Biomechanical limitations of partial pediculectomy in endoscopic spine surgery

BACKGROUND CONTEXT

Transforaminal endoscopic decompression is an emerging minimally invasive surgical technique in spine surgery. The biomechanical effects and limitations of resections associated with this technique are scarce.

PURPOSE

The objective of this study was to analyze the effects of three different extents of reduction at the craniomedial pedicle (10%, 25%, and 50%) and to compare them with the intact native side. In addition, the influence of bone quality on the resistance of the pedicle after reduction was investigated.

STUDY DESIGN

Biomechanical cadaveric study.

METHODS

Thirty lumbar vertebrae originating from six fresh frozen cadavers were tested under uniaxial compression load in a ramp-to-failure test: (1) the reduced pedicle on one side, and (2) the native pedicle on the other side. Of the 30 lumbar vertebrae, ten were assigned to each reduction group (10%, 25%, and 50%).

RESULTS

On the intact side, the median axial compression force to failure was 593 N (442.4-785.8). A reduction of the pedicle by 10% of the cross-sectional area resulted in a decrease of the axial load resistance by 4% to 66% compared to the intact opposite side (p=.046). The median compression force to failure was 381.89 N (range: 336-662.1). A reduction by 25% resulted in a decrease of 7% to 71% (p=.001). The median compression force to failure was 333 N (265.1-397.3). A reduction by 50% resulted in a decrease of 39% to 90% (p<.001). The median compression force to failure was 200.9 N (192.3-283.9). At 10% pedicle reduction, the Hounsfield units (HU) value and the absolute force required to generate a pedicle fracture showed significant correlations (ρ=.872; p=.001). At 25%, a positive correlation between the two variables could still be identified (ρ=.603; p=.065). At 50%, no correlation was found (ρ=-.122; p=.738).

CONCLUSION

Resection of the inner, upper part of the pedicle significantly reduces the axial resistance force of the pedicle until a fracture occurs.

CLINICAL SIGNIFICANCE

The extent of pedicle reduction itself plays only a limited role: once the cortical bone in the pedicle region is compromised, significant loss of resistance to loading must be anticipated.

Pain improvement and reoperation rate after full-endoscopic decompression for lateral recess stenosis: a 10-year follow-up

PURPOSE

To share long-term clinical outcomes and our experience with full-endoscopic interlaminar decompression (FEI) for lateral recess stenosis (LRS).

METHODS

We included all patients who underwent FEI for LRS from 2009 to 2013. VAS for leg pain, ODI, neurological findings, radiographic findings, and complications were analyzed at one week, one month, three months, and one year postoperation. The telephone interview for local patients with simple questions was done approximately ten years after the operation. International patients receive an email with the same questionnaire as local patients during the same follow-up period.

RESULTS

One hundred and twenty-nine patients underwent FEI for LRS with complete data during 2009-2013. Most of the patients (70.54%) had LRS radiculopathy for less than one year, mainly L4-5 (89.92%), followed by L5-S1 (17.83%). Early outcomes three months after surgery showed that most patients (93.02%) reported significant pain relief, and 70.54% reported no pain at their ODI scores were significantly reduced from 34.35 to 20.32% (p = 0.0052). In contrast, the mean VAS for leg pain decreased substantially by 3.77 points (p < 0.0001). There were no severe complications. At ten years of follow-up, 62 patients responded to the phone call or email. 69.35% of the patients reported having little or no back or leg pain, did not receive any further lumbar surgery, and were still satisfied with the result of the surgery. There were six patients (8.06%) who underwent reoperation.

CONCLUSION

FEI for LRS was satisfactory at 93.02%, with a low complication rate during the early follow-up period. Its effect seems to decline slightly in the long term at a 10-year follow-up. 8.06% of the patients subsequently underwent reoperation.

Cost-utility analysis of endoscopic lumbar discectomy following a uniform clinical pathway in the Korean national health insurance system

INTRODUCTION

Full-endoscopic lumbar discectomy (FELD) is a type of minimally invasive spinal surgery for lumbar disc herniation (LDH). Sufficient evidence exists to recommend FELD as an alternative to standard open microdiscectomy, and some patients prefer FELD due to its minimally invasive nature. However, in the Republic of Korea, the National Health Insurance System (NHIS) controls the reimbursement and use of supplies for FELD, but FELD is not currently reimbursed by the NHIS. Nonetheless, FELD has been performed upon patients' request, but providing FELD for patients' sake is inherently an unstable arrangement in the absence of a practical reimbursement system. The purpose of this study was to conduct a cost-utility analysis of FELD to suggest appropriate reimbursements.

METHOD

This study was a subgroup analysis of prospectively collected data including 28 patients who underwent FELD. All patients were NHIS beneficiaries and followed a uniform clinical pathway. Quality-adjusted life years (QALYs) were assessed with a utility score using the EuroQol 5-Dimension (EQ-5D) instrument. The costs included direct medical costs incurred at the hospital for 2 years and the price of the electrode ($700), although it was not reimbursed. The costs and QALYs gained were used to calculate the cost per QALY gained.

RESULT

Patients' mean age was 43 years and one-third (32%) were women. L4-5 was the most common surgical level (20/28, 71%) and extrusion was the most common type of LDH (14, 50%). Half of the patients (15, 54%) had jobs with an intermediate level of activity. The preoperative EQ-5D utility score was 0.48±0.19. Pain, disability, and the utility score significantly improved starting 1 month postoperatively. The average EQ-5D utility score during 2 years after FELD was estimated as 0.81 (95% CI: 0.78-0.85). For 2 years, the mean direct costs were $3,459 and the cost per QALY gained was $5,241.

CONCLUSION

The cost-utility analysis showed a quite reasonable cost per QALY gained for FELD. A comprehensive range of surgical options should be provided to patients, for which a practical reimbursement system is a prerequisite.

Full endoscopic spine surgery

Background

With a dramatic increase in elderly population worldwide, the prevalence of degenerative spine disease is steadily rising. Even though the entire spinal column is affected the problem is more commonly seen in the lumbar, cervical spine and to some extent the thoracic spine. The treatment of symptomatic lumbar disc or stenosis is primarily conservative with analgesics, epidural steroids and physiotherapy. Surgery is advised only if conservative treatment is ineffective. Conventional open microscopic procedures even though are still a gold standard, have the disadvantages of excessive muscle damage and bone resection, epidural scarring along with prolonged hospital stay and increased need of postoperative analgesics. Minimal access spine surgeries minimize surgical access related injury by minimizing soft tissue and muscle damage and also bony resection thus preventing iatrogenic instability and unnecessary fusions. This leads to good functional preservation of the spine and enhances early postoperative recovery and early return to work. Full endoscopic spine surgeries are one of the more sophisticated and advanced form of MIS surgeries.

Purpose

Full endoscopy has definitive benefits over conventional microsurgical techniques. These include better and clear vision of the pathology due to presence of irrigation fluid channel, minimal soft tissue and bone trauma, better and relatively easy approach to deep seated pathologies like thoracic disc herniations and a possibility to avoid fusion surgeries. The purpose of this article is to describe these benefits, give an overview of the two main approaches - transforaminal and interlaminar, their indications, contraindications and their limitations. The article also describes about the challenges in overcoming the learning curve and its future prospectives.

Conclusion

Full endoscopic spine surgery is one of the fastest growing technique in the field of modern spine surgery. Better intraoperative visualization of the pathology, lesser incidence of complications, faster recovery time, less postoperative pain, better relief of symptoms and early return to activity are the main reasons behind this rapid growth. With better patient outcomes and reduced medical costs, the procedure is going to be more accepted, relevant and popular procedure in future.

Local Anesthesia Versus General Anesthesia in Percutaneous Interlaminar Endoscopic Discectomy: A Meta-analysis

OBJECTIVE

The objective of this study was to systematically evaluate the safety and efficacy of local anesthesia (LA) and general anesthesia (GA) in percutaneous interlaminar endoscopic discectomy (PIED).

MATERIALS AND METHODS

We searched MEDLINE, EMBASE, EuropePMC, PubMed, Web of Science, Cochrane databases, and CNKI databases for all relevant studies. All statistical analysis was performed using Review Manager version 5.3.

RESULTS

A total of 6 articles with 549 study participants were included, with 282 patients in LA group and 267 patients in GA group. The results of the meta-analysis showed that the LA group had significantly better results in hospital stay time (mean difference [MD], -1.68; 95% CI, -3.35 to -0.01) and hospital costs (MD, -0.57, 95% CI, -1.02 to -0.12) compared with the GA group; whereas Oswestry Disability Index (MD, 0.48; 95% CI, -0.07 to 1.04), Visual Analog Scale Scores (MD, -0.05; 95% CI, -0.24 to 0.13), postoperative transient dysesthesia and weakness (odds ratio [OR], 0.83, 95% CI, 0.40 to 1.69), dura and nerve root injury (OR, 0.21, 95% CI, 0.03 to 1.25), operation time (MD, -3.51; 95% CI, -11.5 to 4.48), and willingness rate to receive the same procedure(OR, 0.12, 95% CI, 0.01 to 1.00) showed no significant differences between the 2 groups.

DISCUSSION

LA can effectively relieve pain during PIED surgery and ensure the safety of operation without increasing the occurrence of postoperative complications. PIED under LA not only has similar patient satisfaction but also shows obvious advantages in shortening hospital stay and reducing hospital costs compared with GA surgery.