Eight Surgical Interventions for Lumbar Disc Herniation: A Network Meta-Analysis on Complications

Comparison of chemonucleolysis and discectomy in the management of lumbar disc herniation: a comprehensive systematic review and meta-analysis

Lumbar disc herniation (LDH) represents a significant cause of pain and physical impairment, negatively impacting the quality of life, and burdening healthcare systems. Despite numerous treatment strategies, optimal management remains a subject of debate. This meta-analysis aims to compare the efficacy and economic impact of chemonucleolysis (CN) and discectomy in the management of LDH. An extensive search of Embase, PubMed, and Cochrane databases yielded 391 records. Following strict inclusion and exclusion criteria, twenty-one studies suitable for a comparative analysis between CN and discectomy were included. This selection was based on patient improvement, including pain scores, complications, and differences in cost and surgery time. A total of 2436 patients were included in this study. Among them, 1,121 patients (46%) underwent discectomy, while 1,315 patients (54%) received the CN approach. Our analysis revealed that discectomy had a significantly higher improvement rate compared with chymopapain CN (OR: 0.45; 95%CI 0.23,0.88) and non-chymopapain CN (OR: 0.61; 95%CI 0.38,0.97). A non-significant inclination towards complication rates was observed with chymopapain CN (OR: 1.90; 95%CI 0.68,5.29). Notably, CN was associated with a considerable cost reduction (SMD: 7.11; 95%CI -11.37,-2.85) and a shorter surgical time (MD: -53.54; 95%CI -57.91,-49.17) compared with discectomy. The evidence synthesized in this meta-analysis suggests superior clinical outcomes for discectomy when compared to CN in managing LDH. However, CN demonstrated a notable advantage in terms of cost-efficiency and operative time, marking it as a potentially preferable option in resource-constrained settings. Nonetheless, more randomized clinical trials and prospective studies are necessary to confirm these findings.

Clinical efficacy of one-hole split endoscopy vs. unilateral biportal endoscopy for the treatment of single-segment lumbar spinal stenosis: a retrospective study with 2-year follow-up

Background

One-hole split endoscopy (OSE) is a novel endoscopic technique proposed by Chinese scholars in recent years. Currently, data is lacking regarding the long-term efficacy of OSE for treating lumbar spinal stenosis (LSS). This study aimed to compare the long-term efficacy of OSE and unilateral biportal endoscopy (UBE) in LSS treatment.

Methods

The clinical data of 77 patients diagnosed with LSS at our hospital between January 2020 and March 2022 were retrospectively analyzed. Forty-one patients were treated with OSE, and 36 were treated with UBE. Perioperative indicators such as operation time, blood loss, fluoroscopy times, incision length, hospital stay, follow-up time, complications, and C-reactive protein level preoperatively and 3 days postoperatively were recorded. Visual analog score (VAS) and Oswestry disability index (ODI) were recorded preoperatively and at 1, 3, 6, 12, and 24 months postoperatively to evaluate pain and functional disability. The dural sac cross-sectional area (CSA), lumbar range of motion (ROM), and sagittal translation (ST) of the surgical segment were recorded preoperatively and 3 days postoperatively to evaluate lumbar stability. Clinical efficacy was assessed at the final follow-up using the modified Macnab criteria.

Results

VAS and ODI scores significantly improved at each postoperative follow-up in both groups compared with preoperative values (P < 0.05), with no significant difference between the groups (P > 0.05). However, OSE had a shorter operation time, less blood loss, and shorter incision length than UBE (P < 0.05). Postoperative CSA was significantly increased compared to the preoperative CSA (P < 0.05), with no significant difference between the groups (P > 0.05). Postoperative ROM and ST increased; however, there was no significant difference compared to preoperative values (P > 0.05). The complication rates in the OSE (n = 2, 4.88%) and UBE (n = 2, 8.33%) groups were not significantly different (x 2 = 0.023; P = 0.880). Clinical efficacy was assessed at the last follow-up using the modified MacNab criteria. Thirty-eight (92.68%) and 34 (94.44%) patients in the OSE and UBE groups, respectively, demonstrated excellent or good efficacy, with no significant difference in the efficacy rate between the groups (x 2 = 0.151, P = 0.985).

Conclusion

OSE and UBE showed satisfactory long-term efficacy and safety for LSS treatment. However, OSE has a shorter operation time, less blood loss, and shorter incision length, and can be an alternative to UBE.

Are large language models valid tools for patient information on lumbar disc herniation? The spine surgeons' perspective

Introduction

Generative AI is revolutionizing patient education in healthcare, particularly through chatbots that offer personalized, clear medical information. Reliability and accuracy are vital in AI-driven patient education.

Research question

How effective are Large Language Models (LLM), such as ChatGPT and Google Bard, in delivering accurate and understandable patient education on lumbar disc herniation?

Material and methods

Ten Frequently Asked Questions about lumbar disc herniation were selected from 133 questions and were submitted to three LLMs. Six experienced spine surgeons rated the responses on a scale from "excellent" to "unsatisfactory," and evaluated the answers for exhaustiveness, clarity, empathy, and length. Statistical analysis involved Fleiss Kappa, Chi-square, and Friedman tests.

Results

Out of the responses, 27.2% were excellent, 43.9% satisfactory with minimal clarification, 18.3% satisfactory with moderate clarification, and 10.6% unsatisfactory. There were no significant differences in overall ratings among the LLMs (p = 0.90); however, inter-rater reliability was not achieved, and large differences among raters were detected in the distribution of answer frequencies. Overall, ratings varied among the 10 answers (p = 0.043). The average ratings for exhaustiveness, clarity, empathy, and length were above 3.5/5.

Discussion and conclusion

LLMs show potential in patient education for lumbar spine surgery, with generally positive feedback from evaluators. The new EU AI Act, enforcing strict regulation on AI systems, highlights the need for rigorous oversight in medical contexts. In the current study, the variability in evaluations and occasional inaccuracies underline the need for continuous improvement. Future research should involve more advanced models to enhance patient-physician communication.

Evaluation of Spin in Systematic Reviews and Meta-Analyses of Minimally Invasive Surgical Techniques and Standard Microdiscectomies for Treating Lumbar Disc Herniation

STUDY DESIGN

Systematic review.

OBJECTIVES

Spin in scientific literature is defined as bias that overstates efficacy and/or underestimates harms of procedures undergoing review. While lumbar microdiscectomies (MD) are considered the gold standard for treating lumbar disc herniations (LDH), outcomes of novel procedures are being weighed against open MD. This study identifies the quantity and type of spin in systematic reviews and meta-analyses of LDH interventions.

METHODS

A search was conducted on the PubMed, Scopus, and SPORTDiscus databases for systematic reviews and meta-analyses evaluating the outcomes of MD against other LDH interventions. Each included study's abstract was assessed for the presence of the 15 most common types of spin, with full texts reviewed during cases of disagreement or for clarification. Full texts were used in the assessment of study quality per AMSTAR 2.

RESULTS

All 34 included studies were observed to have at least 1 form of spin, in either the abstract or full text. The most common type of spin identified was type 5 ("The conclusion claims the beneficial effect of the experimental treatment despite a high risk of bias in primary studies"), which was observed in ten studies (10/34, 29.4%). There was a statistically significant association between studies not registered with PROSPERO and the failure to satisfy AMSTAR type 2 (P < .0001).

CONCLUSION

Misleading reporting is the most common category of spin in literature related to LDH. Spin overwhelmingly tends to go in the positive direction, with results inappropriately favoring the efficacy or safety of an experimental intervention.

Cost and Effectiveness of Percutaneous Endoscopic Interlaminar Discectomy versus Microscope-Assisted Tubular Discectomy for L5-S1 Lumbar Disc Herniation

OBJECTIVE

To assess the cost and effectiveness of percutaneous endoscopic interlaminar discectomy (PEID) and microscope-assisted tubular discectomy (MATD) for patients with L5/S1 lumbar disc herniation (LDH).

METHODS

The medical and financial records of patients diagnosed with L5/S1 LDH and who underwent either PEID or MATD from April 2021 to April 2022 were retrospectively collected. Demographic and baseline information, perioperative observational index, clinical outcomes, and inpatient costs were analyzed.

RESULTS

Sixty patients were included, with 30 patients in the PEID group and 30 patients in the MATD group. No significant difference was found in demographic and baseline information between the 2 groups (P > 0.05). The PEID group showed significantly shorter incision length, less intraoperative blood loss, shorter hospital stays, and higher intraoperative fluoroscopy frequency compared with the MATD group (P < 0.05). There were no significant differences in visual analog scale back/leg score, Oswestry Disability Index, and 36-Item Short-Form Survey score between PEID and MATD groups before the surgery and at any follow-up time points (P > 0.05). The total cost, surgery cost, and surgical instruments/materials cost were significantly higher in the PEID group compared with the MATD group (P < 0.05). In contrast, the drug and nursing costs were significantly higher in the MATD group than in the PEID group (P < 0.05).

CONCLUSIONS

PEID and MATD provide equivalent clinical efficacy and safety in treating LDH at L5/S1 segment within a 1-year follow-up. However, PEID is less invasive and MATD is less costly. No one surgical technique is superior in all aspects and patients should make decisions according to their top concern.

Comparison of posterior decompression techniques and conventional laminectomy for lumbar spinal stenosis

Objectives

To compare the efficacy of posterior decompression techniques with conventional laminectomy for lumbar spinal stenosis.

Methods

The Embase, PubMed, and Cochrane Library databases were searched with no language limitations from inception to January 13, 2022. The main outcomes were functional disability, perceived recovery, leg and back pain, complications. A random effects model was used to pooled data. Risk ratio (RR), mean difference (MD) and 95% confidence interval (CI) were used to report results. The study protocol was published in PROSPERO (CRD42022302218).

Results

14 trials including 1,106 participants were included in the final analysis. Bilateral laminotomy was significantly more efficacious in improve functionality than laminectomy [MD: -2.94; (95% CI, -4.12 to -1.76)]. Low incidence of iatrogenic instability due to bilateral laminectomy compared with laminectomy [RR: 0.11; (95% CI, 0.02 to 0.59)]. In addition, between those who received bilateral laminotomy and those undergoing laminectomy, the result showed significant difference regarding recovery [RR: 1.31; (95% CI, 1.03 to 1.67)].

Conclusions

This study provides evidence that bilateral laminotomy has advantages in functional recovery, postoperative stability, and postoperative rehabilitation outcomes. Further research is needed to determine whether posterior techniques provide a safe and effective option for conventional laminectomy.

Association of robot-assisted techniques with the accuracy rates of pedicle screw placement: A network pooling analysis

BACKGROUND

Traditional paired meta-analyses have yielded inconsistent results for the safety and effectiveness of robotic-assisted pedicle screw placement due to the high heterogeneity within studies. This study evaluated the clinical effectiveness and safety of robotic-assisted pedicle screw placement.

METHODS

The Embase, PubMed, and Cochrane Library databases were searched with no language limitations from inception to Jan 4, 2022. Odds ratio (OR), mean difference (MD), and 95% confidence interval (CI) were used to report results. The main outcomes were accuracy of pedicle screw placement, proximal facet joint violation, and complications. The study protocol was published in PROSPERO (CRD42022301417).

FINDINGS

26 trials including 2046 participants evaluating robotic-assisted pedicle screw placement were included in this study. Our pooled results showed that Renaissance (OR 2.86; [95% CI 1.79 to 4.57]) and TiRobot (OR 3.10; [95% CI 2.19 to 4.40]) yielded higher rates of perfect pedicle screw insertion (Grades A) than the conventional freehand technique. Renaissance (OR 2.82; [95% CI 1.51 to 5.25]) and TiRobot (OR 4.58; [95% CI 2.65 to 7.89]) yielded higher rates of clinically acceptable pedicle screw insertion (Grades A+B). However, ROSA, SpineAssist, and Orthobot were not associated with higher perfect pedicle screw insertion and clinically acceptable pedicle screw insertion rates. Robot-assisted techniques were associated with low rates of proximal facet joint violation (OR 0.18; [95% CI 0.10 to 0.32]; I²:9.55%) and overall complications (OR 0.38; [95% CI 0.23 to 0.63]; I²:27.05%). Moreover, robot-assisted techniques were associated with lower radiation doses (MD -14.38; [95% CI -25.62 to -3.13]; I²:100.00%).

INTERPRETATION

Our findings suggest that only Renaissance and TiRobot systems are associated with high accuracy rates of pedicle screw placement. Robotic-assisted techniques hold great promise in spinal surgery due to their safety and effectiveness.

FUNDING

This work was supported by grants from the National Natural Science Foundation of China (No. 81871818), Tangdu Hospital Seed Talent Program (Fei-Long Wei) and Natural Science Basic Research Plan in Shaanxi Province of China (No.2019JM-265).

The Learning Curve of Unilateral Biportal Endoscopic (UBE) Spinal Surgery by CUSUM Analysis

Objective

To assess the learning curve of the unilateral biportal endoscopic (UBE) technique for the treatment of single-level lumbar disc herniation by cumulative summation (CUSUM) method analysis.

Methods

A retrospective analysis was conducted to assess 97 patients' general condition, operation time, complications, and curative effect of single segmental UBE surgery performed by a spinal surgeon in his early stage of this technique. The learning curve of operation time was studied using a CUSUM method, and the cut-off point of the learning curve was obtained.

Results

The operation time was 30 – 241(97.9 ± 34.7) min. The visual analog scale score of lower limb pain decreased from 5.75 ± 0.81 before the operation to 0.39 ± 0.28 at the last follow-up (P &lt; 0.05). The Oswestry disability index score decreased from 66.48 ± 4.43 before the operation to 14.57 ± 3.99 at the last follow-up (P &lt; 0.05). The CUSUM assessment of operation time revealed the learning curve was the highest in 24 cases. In the learning stage (1–24 cases), the operation time was 120.3 ± 43.8 min. In the skilled stage (25–97 cases), the operation time was 90.5 ± 27.8 min.

Conclusions

About 24 cases of single segmental UBE operation are needed to master the UBE technique.