Comparison of the efficacy of fully endoscopic spine surgery using transforaminal and interlaminar approaches in the treatment of prolapsed lumbar 4/5 disc herniation

Real-time video communication during percutaneous transforaminal endoscopic discectomy is beneficial to postoperative recovery: a single-center retrospective study

PURPOSE

To evaluate the effect of intraoperative viewing of real-time surgical video and communication among patients on postoperative recovery and satisfaction after percutaneous transforaminal endoscopic discectomy (PTED).

METHOD

Patients admitted to our medical center from January 1, 2021 to December 1, 2023 who underwent PTED for L4/5 lumbar disc herniation were collected. We finally included 77 patients who met the inclusion and exclusion criteria. Patients were categorized into communication (CM) group (n = 39) and non-communication (NCM) group (n = 38) according to whether they had intraoperative real-time surgical video viewing and communication. Preoperative baseline data, operative time, postoperative hospitalization time, Visual Analogue Scale(VAS) score, lumbar Japanese Orthopaedic Association (JOA) score, surgical complications and patient satisfaction were compared between the two groups.

RESULT

Patients in the CM group had less pain, faster functional recovery, shorter hospitalization, and higher satisfaction in the early postoperative period. The NCM group had a shorter operative time. However, patients in the CM group had lower VAS scores on the first day after surgery and at 1 month after surgery than those in the NCM group. And JOA scores were better in the communication group at the first week and first month after operation. There was no significant difference between the two groups in terms of VAS scores, JOA scores, and postoperative complications in the third and sixth postoperative months.

CONCLUSION

Allowing patients to watch real-time surgical videos and engage in intraoperative communication during PTED surgery is a feasible way to reduce early postoperative pain, accelerate functional recovery, and improve patient satisfaction.

Electromagnetic Navigation in Biportal Endoscopic Lumbar Spine Surgery

Introduction

Endoscopic Spine Surgery (ESS) has begun to gain traction as an alternative to traditional microscopic spine surgery, particularly for lumbar decompression. However, one of the challenges associated with this approach is the steep learning curve. A recent advancement in this field aims to flatten the learning curve by incorporating navigation into ESS. This technology provides valuable information on the extent of decompression, confirms the working level, and reduces radiation exposure.

Technical Note

We aimed to describe our experience using electromagnetic navigation in biportal endoscopic spine surgery (BESS). The surgical technique is initiated by positioning the patient prone on a radiolucent table. The navigation field generator is positioned over the caudal end of the patient. The navigation system is set up with patient mappers at the desired working levels. The patient tracker is implanted. The final fluoroscopy images are captured in anteroposterior and lateral views. Subsequently, standard incisions are made, and endoscopic decompression is performed. When required, various instruments can be used to confirm the level, angulation, and extent of decompression.

Conclusions

Our experience showed that this approach reduced the need for intraoperative imaging and provided an accurate alternative to repeated intraoperative imaging. However, it does involve a significantly long setup. Further trials of larger scale are required to determine its efficacy.

Full-endoscopic lumbar spine discectomy: Are We Finally There? A Meta-Analysis of Its Effectiveness Against Non-microscopic Discectomy, Microdiscectomy and Tubular Discectomy

BACKGROUND CONTEXT

Full-endoscopic lumbar discectomy (FELD) has gained increasing attention as a minimally invasive alternative to conventional microdiscectomy (MD), tubular discectomy (MED), and open non-microscopic discectomy (OD) Despite significant technological advancements in endoscopic techniques over the past decade, it is not yet clear whether FELD offers a definitive advantage over traditional methods.

PURPOSE

This study aims to perform a meta-analysis of available publications to assess whether the superiority of endoscopic treatment over traditional open and minimally invasive endoscopic surgical techniques can be more conclusively established. The central question driving this meta-analysis was: Are we finally there?

STUDY DESIGN/SETTING

Meta-analysis study included adult patients (≥18 years old) with symptomatic lumbar disc herniation (LDH) without concurrent lumbar spinal stenosis METHODS: A systematic review was conducted in PubMed, Embase, Web of Science, and the Cochrane Library for randomized or nonrandomized controlled trials published between 2013 and 2024. The quality of randomized controlled trials and cohort studies was assessed using the Revised Cochrane risk-of-bias tool and Newcastle-Ottawa Scale, respectively. Included studies reported on at least one of the following outcomes: (1) adverse effects, (2) operative parameters, (3) bed and hospital stay, and (4) clinical indices (postoperative values). Mean differences (MDs) or odds ratios (ORs) were used to compare treatment effects between FELD and MD, MED, or OD.

RESULTS

FELD demonstrated several advantages, particularly in short-term pain (within 6 months postoperatively) relief and faster patient (length of bed stay 1-2 days) mobilization, while maintaining comparable risks of recurrence, reoperation, and complications relative to traditional techniques. However, there is substantial heterogeneity in the data and a limited number of prospective trials.

CONCLUSIONS

More well-designed, prospective randomized trials are necessary, with a focus on radiological outcomes and comprehensive cost analyses including societal costs. Only through such robust data can we determine whether FELD truly represents a new gold standard for lumbar discectomy. Are we finally there? We are certainly closer, but much remains to be addressed.

Percutaneous Endoscopic Suprapedicular Decompression in the Treatment of Down-Migrated Lumbar DiscHerniation

OBJECTIVE

This study aimed to investigate the clinical efficacy of percutaneous endoscopic suprapedicular decompression in treatment of down-migrated lumbar disc herniation.

METHODS

The clinical data of 43 patients with down-migrated lumbar disc herniation treated with endoscopic surgery at our hospital between January 2022 and January 2023 were retrospectively analyzed. Twenty-two and 21 patients underwent percutaneous endoscopic decompression using the suprapedicular and transforaminal endoscopic surgical system approaches, respectively. The perioperative, follow-up, and imaging data of the groups were compared.

RESULTS

Surgery was uneventful in both groups. The number of intraoperative fluoroscopies and duration of surgery were significantly lower in the suprapedicular group (P < 0.05). The patients in both groups were followed up for at least 12 months. At the last follow-up, lumbar pain and leg pain visual analog scale, Oswestry Disability Index, and 36-Item Short Form Health Survey scores were significantly improved in both groups compared with preoperative values (P < 0.05); the differences in these indexes between the 2 groups were not significant preoperatively (P > 0.05). However, at the last postoperative follow-up, lumbar pain visual analog scale scores were significantly better in the suprapedicular group (0.83 ± 0.85 vs. 2.54 ± 1.32, P < 0.05). There was no significant change in intervertebral space height or lumbar lordotic angle compared with preoperative values in either group at the last follow-up (P > 0.05). However, the spinal canal cross-sectional area significantly increased (P < 0.05).

CONCLUSIONS

The treatment of down-migrated lumbar disc herniation via a suprapedicular approach enabled the incision of the superior margin of the pedicle as needed under direct vision, involved less fluoroscopy while preserving facet joint stability, and enabled targeted removal of the herniated nucleus pulposus, thus greatly reducing residual nucleus pulposus. This surgical procedure was safe, rapid, and showed satisfactory therapeutic efficacy.

A Modified Laminotomy for Interlaminar Endoscopic Lumbar Discectomy: Technical Report and Preliminary Results

OBJECTIVE

To introduce a technique of laminotomy using a common trephine to enlarge the interlaminar space at L4/5 segment for interlaminar endoscopic lumbar discectomy (IELD) and report the anatomical basis of this procedure, technical details, as well as primary clinical outcomes of a consecutive patient cohort with L4/5 lumbar disc herniation (LDH).

METHODS

On anteroposterior fluoroscopy, the intersection of the medial edge of the inferior articular process and the inferior endplate of L4 vertebra was taken as the target. Using a common trephine, laminotomy was performed to remove a big portion of the posterior wall of the canal under the guidance of endoscopy. From June 2018 to December 2021, the consecutive patients who underwent L4/5 IELD were prospectively studied. Clinical outcomes were assessed at the day before surgery, 1 day, 1 month, 3 months, 12 months after surgery, and the last follow-up. Numerical Rating Scale, Roland-Morris Disability Questionnaire (RMDQ), and MacNab criteria were used to evaluate back and leg pain, the quality of life, and clinical efficacy, respectively.

RESULTS

There were 64 men and 44 women, with an age of 50.3 ± 14.9 years. The operating time was 74.54 ± 17.42 minutes. The mean follow-up time was 32.7 ± 18.6 months (range, 12-64 months). The complications of IELD included numbness, neck pain, and recurrence. Both leg pain (6.2 ± 1.9 vs. 1.8 ± 0.8, p < 0.001) and back pain (3.1 ± 2.3 vs. 1.7 ± 0.9, p < 0.001) quickly improved after this procedure and maintained (1.1 ± 1.5, 1.1 ± 1.3) at final follow-up. Physical disability due to back pain, as assessed using RMDQ, was improved remarkably after surgery (15.0 ± 5.8 vs. 2.9 ± 4.1, p < 0.001). In addition, MacNab outcome grade was evaluated as good-to-excellent in 96 cases (88.9%).

CONCLUSION

A convenient technique of laminotomy using a common trephine was proposed for the L4/5 IELD. It can efficiently enlarge the interlaminar entry to perform endoscopic discectomy. This procedure is particularly suitable for treating LDH with concomitant lumbar spinal stenosis and migrated herniated disc.

Comparison of the Interlaminar and Transforaminal Approaches for Full-endoscopic Discectomy for the Treatment of L4/5 Lumbar Disc Herniation

This study aims to compare the outcomes of interlaminar and transforaminal approaches for full-endoscopic discectomy (FED) for treating L4/5 lumbar disc herniation (LDH).A retrospective study of patients with L4/5 LDH treated with interlaminar endoscopic lumbar discectomy (IELD, n = 19) or transforaminal endoscopic lumbar discectomy (TELD, n = 105) was conducted. Patient background, radiological findings, and operative data were collected. Oswestry Disability Index (ODI) and European Quality of Life-5 Dimension (EQ-5D) scores were recorded preoperatively and 1 and 2 years postoperatively.Although ODI and EQ-5D scores 1 and 2 years postoperatively improved statistically in the IELD and TELD groups, there were no statistical differences between the groups. IELD was predominantly performed in patients who were taller and heavier. The mean operative times and the frequency of laminectomy for IELD and TELD were 67.2 and 44.6 min and 63.2 and 17.1%, respectively (P < 0.001). The radiological findings showed that the concave configuration of the L4 lamina, interlaminar space width, and foraminal width were statistically different between the groups. There were no complications in either of the groups. Reoperation was required for recurrence in two and five patients in the IELD and TELD groups (P = 0.29), respectively.Operative outcomes were identical between the two groups. Although the operative time was longer in the IELD group, both approaches were safely and effectively performed. Depending on the patient's physique and preoperative radiological findings, the more suitable approach for L4/5 LDH should be chosen.