Microendoscopic lumbar discectomy: Technique and results of 188 cases

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.

Symptom recurrence and associated factors in postoperative patients with lumbar degenerative disease

[Purpose] This study aimed to examine gradual changes in and relationships among preoperative and 3-month postoperative endpoints in patients with lumbar degenerative disease. [Participants and Methods] The study included 160 diagnosed with lumbar degenerative diseases who underwent surgery. Patients were divided into two groups: "good progress" and "recrudescence". Changes in the Japan Orthpedics Associations (JOA) score, JOA back pain evaluation questionnaire (JOABPEQ), and numeric rating scale (NRS) preoperatively and 3 months postoperatively, and their associations, were analyzed. [Results] Differences were found in preoperative NRS for low back pain, JOA score (other findings) at 3 months postoperatively, and NRS for low back pain at 3 months postoperatively. The causal analysis yielded paths for "daily life", "pain", and "social/psychological aspects", starting with "lumbar spine disorders". [Conclusion] The subjective symptoms, objective findings, lumbar spine dysfunction, gait dysfunction, and numbness at 3 months postoperatively yielded relevant information regarding the participants activities of daily living, pain, and social and psychological aspects, providing a perspective for monitoring postoperative patients.

An assessment of the variation in the practice of lumbar discectomy and its role in axial back pain

Background

Lumbar discectomy is performed for symptomatic lumbar disc herniation and is one of the most widely performed spinal surgical procedures worldwide in a variety of ways. This survey aimed at providing an overview/perspective of different practice patterns and the impact of lumbar discectomy on axial back pain with or without sciatica.

Methods

An online survey was performed using the application "Google Forms." The link to the questionnaire was distributed to neurosurgeons through personal E-mail and social media platforms.

Results

We received 333 responses. The largest percentage of responses across five continents was from Asia (66.97%, n = 223). The mean age of the respondents was 40.08 ± 10.5 years. A total of 66 respondents (20%) had a spine practice of 7%-90%, and 28 respondents had a spine practice of 90%-100% (8.4%). The number of respondents who practiced microscopic discectomy using a tubular retractor (n = 143 respondents, 42.9%) was nearly equal to the number of respondents who practiced open discectomy (n = 142 respondents, 42.6%). An almost equal proportion of respondents believed discectomy does not help in relieving axial back pain. Only 20.4% (n = 68) of respondents recommend bed rest for a longer duration postoperatively.

Conclusions

Our survey revealed that only 22.2% of spine surgeons recommended discectomy in patients with radiological disc herniation with axial back pain alone and preferred a minimally invasive method of discectomy. Almost half of them believed discectomy to be ineffective for axial low back pain and only a few recommended prolonged bed rest postoperatively.

Outcome of Transforaminal Endoscopic Discectomy in Rural India in a Single-Level Lumbar Disc Prolapse Under Local Anesthesia

Aim  The aim of this study was to undertake a clinical study to evaluate the outcomes of transforaminal endoscopic discectomy under local anesthesia and to study the complication rate. Study Design  It is a prospective study. Methods  We prospectively analyzed outcomes of 60 patients with a single-level lumbar disc prolapse in rural India from December 2018 to April 2020 who underwent endoscopic discectomy under local anesthesia. Follow-up was done using the visual analogue score (VAS) and Oswestry Disability Index (ODI) scoring systems with a minimum follow-up up to 1 year postoperatively. Results  In our study of 60 patients, there was 38 cases of L4-L5 disc pathology, 13 L5-S1 discs, and 9 L3-L4 discs. Our study showed a significant clinical reduction in mean VAS score that was 7.07/10 preoperatively and reduced to 3.88/10 at the third month and 3.64/10 at 1 year of follow-up ( p -value < 0.05) showing clinical significance. The ODI scoring done preoperatively was an average mean of 57.37% pointing to how crippled the patients were with lumbar disc prolapse and showed a significant reduction to 29.32% postoperatively at 1 year ( p -value < 0.05) showing clinical significance. This reduction in ODI directly corelates to how almost all patients returned to normal life coping to all activities and were completely pain free at 1 year of follow-up. Conclusion  Endoscopic spine surgery in lumbar disc prolapse is highly effective and can deliver a good functional outcome if done with correct preoperative planning and approach.

Endoscopic Lumbar Discectomy Using Side-Viewing Conical Working Tube: An Institutional Experience

Objective The paradigm of surgical therapy for spinal disease especially for lumbar disc herniation (LDH) has gradually shifted from the traditional open surgeries to minimal invasive spinal surgeries. Endoscopic discectomy has been performed widely using various devices and techniques. In this study we present our experience of endoscopic discectomy using a unique device with separate side-viewing channel.

Methods Twenty-six patients with LDH treated between March 2015 and April 2018 using the unique conical working tube with separate side-viewing endoscopic channel have been retrospectively analyzed. Their preoperative and postoperative Oswestry Disability Index (ODI) and Macnab scores were used to evaluate the outcome with a mean follow-up of 37.04 months.

Results There were 18 males and 8 females with age ranging from 19 to 72 years (mean, 38.4 years). The follow-up ranged from 25 to 60 months with mean of 37.04 months. The mean preoperative ODI score was 72.4, which decreased to a mean of 7.6 and the outcome evaluated by Macnab criteria was 65.3% excellent, 19.2% good, 11.5% fair, and 3.8% poor. One patient underwent second surgery. None of the patients had to change their occupation postoperatively. Complications that occurred were dural tear in one patient and transient foot paresis in one, which improved spontaneously.

Conclusion Endoscopic discectomy using conical working tube is a safe and effective technique for lumbar disc prolapse. The long-term results are comparable to the conventional techniques.

History of Endoscopic Spine Surgery in India

Endoscopic spine surgeries provide distinct advantages and is therefore a viable alternative to open or microscopic techniques. Indian surgeons have shown their expertise from craniovertebral junction to lumbosacral spine with these techniques. Many novel approaches like endoscopic transcervical, partial corpectomy, and others have been designed, and many technological innovations for these surgeries have been made. With different training programs attracting both native and international surgeons, the future of endoscopic spine surgery is bright.

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

OBJECTIVES

Various techniques of performing lumbar discectomy are prevalent, each having its rationale and claimed benefits. The authors ventured to assess the perioperative factors, outcomes, and complications of each procedure and compare among them with 946 patients contributed by 10 centers and operated by experienced surgeons.

METHODS

This was a retrospective study of patients operated using open discectomy, microdiscectomy, microendoscopic discectomy, interlaminar endoscopic lumbar discectomy, transforaminal endoscopic lumbar discectomy, and Destandau techniques with a follow-up of minimum 2 years. The inclusion criteria were age >18 years, failed conservative treatment for 4-6 weeks, and the involvement of a single lumbar level.

RESULTS

There was a significant improvement in the visual analog scale score of back, leg, and Oswestry Disability Index scores postoperatively across the board, with no significant difference between them. Minimally invasive procedures (microendoscopic discectomy, interlaminar endoscopic lumbar discectomy, transforaminal endoscopic lumbar discectomy, and Destandau techniques) had shorter operation time, hospital stay, better cosmesis, and decreased blood loss compared with open procedures (open discectomy and microdiscectomy). The overall complication rate was 10.1%. The most common complication was recurrence (6.86%), followed by reoperation (4.3%), cerebrospinal fluid leak (2.24%), wrong level surgery (0.74%), superficial infection (0.62%), and deep infection (0.37%). There were minor differences in incidence of complications between techniques.

CONCLUSION

Although minimally invasive techniques have some advantages over the open techniques in the perioperative factors, all the techniques are effective and provide similar pain relief and functional outcomes at the end of 2 years. The various rates of individual complications provide a reference value for future studies.

PAIN INTENSITY AND FUNCTIONALITY AFTER PERCUTANEOUS ENDOSCOPIC DISCECTOMY: A RETROSPECTIVE COHORT STUDY

ABSTRACT Objectives To evaluate pain intensity and functional status before and 30 days following percutaneous lumbar endoscopic discectomy. Methods A retrospective cohort study that included patients who underwent percutaneous endoscopic discectomy from January 2019 to October 2020 at the Irmandade Santa Casa de Misericórdia Hospital, in Porto Alegre. The data were collected from the electronic medical records of the patients by two independent physicians. Clinical outcomes were assessed using visual analog scale (VAS) and Oswestry Disability Index (ODI) scores. Results Forty-six patients with a mean age of 52.6 ± 15.8 years, 27 of whom (58.7%) were male, were evaluated. Regarding clinical outcomes, a statistically significant improvement was observed in the comparison between the pre- and 30-day postoperative VAS and ODI scores, with no significant difference in relation to sex. No peri- or postoperative complications were observed. All patients successfully completed surgery and were discharged after recovery from anesthesia. Conclusion There was a significant improvement in pain and functional status 30 days after percutaneous endoscopic discectomy performed to correct lumbar disc herniation, with no difference in relation to sex. In addition, no peri- or postoperative complications were observed. Future studies, with longer follow-up times, comparing clinical outcomes from the various techniques of percutaneous endoscopic discectomy are necessary. Level of evidence III; Retrospective comparative study.

Learning Curve of Microendoscopic Discectomy in Single-Level Prolapsed Intervertebral Disc in 120 Patients

STUDY DESIGN

Retrospective study of prospectively collected data.

OBJECTIVE

To evaluate learning curve of tubular microendoscopic discectomy (MED) in lumbar prolapsed intervertebral disc (PIVD) patients based on surgical and clinical parameters and delineate the challenges faced in early cases while practicing MED in large series of patients.

METHODS

This study was an institutional review board-approved retrospective study of the first 125 consecutive patients with single-level lumbar PIVD managed with tubular MED from 2008 to 2016 with a minimum 2-year follow-up. A total of 120 patients available at final follow-up were divided into quartiles (30 each) as per the date of surgery, with each consecutive group serving as a control for the previous group. Preoperatively and postoperatively clinical parameters (pain scores [Visual Analogue Scale; VAS], functional disability [Oswestry Disability Index; ODI] score, modified MacNab criteria), perioperative parameters (operative time, blood loss, hospital stay), technical issues (guide wire migration, tube docking-related problems, dural tear), and postoperative complications (postoperative leg pain, neural injury, infection, recurrence) were evaluated. Statistical analysis-logarithm curve-fit regression analysis and ANOVA test.

RESULTS

The sample consisted of 75 males and 45 females (mean age: 42.54 years) with no significant difference among the quartiles. There was significant difference (P < .005) noted in mean operative time (quartile 1, 87.33 minutes; quartile 2, 58.5 minutes) and mean blood loss (quartile 1, 76.33 mL; quartile 2, 32.66 mL) between quartile 1 and quartile 2, with no further significant reduction in quartile 3 and quartile 4. Significant difference (P < .005) in clinical parameters (VAS preoperative/postoperative 5.28/0.99; ODI preoperative/postoperative 32.18/12.08) were noted but was not associated with surgical experience. Overall, 90% (108 out of 120) of the patients had good to excellent results according to the modified MacNab criteria. The mean hospital stay did not show any significant difference among the quartiles. Guide wire migrated issues, neural injury, dural tear, and tube docking-related problems were significantly reduced after quartile 1. However, recurrence occurred at any phase. Infection occurred in one patient in quartile 1. Although blood loss and operative time showed a declining trend, it was not significant after quartile 2. So asymptote lay in quartile 1 and we recommend that novice surgeon should perform 25 to 30 cases to achieve mastery in this technique.

CONCLUSION

For mastering the art of tubular MED for lumbar PIVD and to reduce its learning curve, novice surgeons can avoid the challenges and problems faced during initial cases with improvement in surgical skills by practicing on cadavers, wet labs, and bone-saw models following certain recommendations that we have after achieving asymptote. Familiarity with instrumentation, communication between surgical team, and defined expectations from radiology technicians are key to reduce the learning curve.

Interlaminar Endoscopic Lumbar Discectomy Using a New 8.4-mm Endoscope and Nerve Root Retractor

STUDY DESIGN

Surgical technique.

OBJECTIVE

Using an 8.4-mm endoscope and endoscopic nerve root retractor, the interlaminar endoscopic lumbar discectomy (IELD) technique is introduced for lumbosacral levels.

SUMMARY OF BACKGROUND DATA

Although spine surgeons are familiar with IELD, this technique is only used for L5-S1 disk herniations and requires a wide interlaminar space.

METHODS

Using an 8.4 mm-endoscope, high-speed drill, and endoscopic Kerrison punches, a nerve-root retractor facilitated the simultaneous medial retraction of the nerve root and removal of the disk fragment by the instrument's cannula. Clinical parameters such the visual analog scale scores for back and leg pain, modified Macnab criteria, and Oswestry Disability Index were analyzed.

RESULTS

A total of 101 patients were enrolled. The visual analog scale scores for back and leg pain significantly decreased from 6.8±2.1 and 7.8±1.5 to 2.0±0.6 and 1.78±1.1, respectively, at the 1-year follow up (P<0.01). The Oswestry Disability Index score significantly improved from 28.6±11.7 to 7.4±2.9 (P<0.01). Ninety-nine patients (97.1%) showed good outcomes.

CONCLUSIONS

A new IELD technique and instruments can overcome the drawbacks of existing IELD with adequate bone work and control of the affected nerve root.

Comparison of microendoscopic discectomy and open discectomy for single-segment lumbar disc herniation

BACKGROUND

Lumbar disc herniation is a common disease. Endoscopic treatment may have more advantages than traditional surgery.

AIM

To compare the clinical efficacy and safety of microendoscopic discectomy (MED) and open discectomy with lamina nucleus enucleation in the treatment of single-segment lumbar intervertebral disc herniation.

METHODS

Ninety-six patients who were operated at our hospital were selected for this study. Patients with single-segment lumbar disc herniation were admitted to the hospital from March 2018 to March 2019 and were randomly divided into the observation group and the control group with 48 cases in each group. The former group underwent lumbar discectomy and the latter underwent laparotomy and nucleus pulpectomy. Surgical effects were compared between the two groups.

RESULTS

In terms of surgical indicators, the observation group had a longer operation time, shorter postoperative bedtime and hospital stay, less intraoperative blood loss, and smaller incision length than the control group (P < 0.05). The excellent recovery rate did not differ significantly between the observation group (93.75%) and the control group (91.67%). Visual analogue scale pain scores were significantly lower in the observation group than in the control group at 1 d, 3 d, 1 mo, and 6 mo after surgery (P < 0.05). The incidence of complications was significantly lower in the observation group than in the control group (6.25% vs 22.92%, P < 0.05).

CONCLUSION

Both MED and open discectomy can effectively improve single-segment lumbar disc herniation, but MED is associated with less trauma, less bleeding, and a lower incidence of complications.

Transforaminal Endoscopic Lumbar Discectomy: Clinical Outcomes and Complications

Objective  To evaluate the clinical and functional results of transforaminal endoscopic lumbar discectomy. Materials and Methods  From August 2015 to January 2017, 101 patients with lumbar disc hernia refractory to clinical treatment underwent endoscopic discectomy. Through clinical evaluation by the Visual Analogue Scale and functional evaluation by the Oswestry Disability Index questionnaire, the patients were analyzed in the preoperative period, the immediate postoperative period, at 1 month, 3 months, 6 months and 1 year after surgery. Results  The mean age of the participants was 48.1 years. The most affected disc levels were L4-L5 and L5-S1. A total of 29 patients were treated at 2 disc levels. After 1 month of postoperative follow-up, the mean scores on the questionnaires (VAS and ODI) decreased significantly ( p  < 0.001). Conclusion  Transforaminal endoscopic Lumbar discectomy has been shown to be a safe, effective and minimally-invasive alternative for the treatment of lumbar disc herniation. The procedure has advantages, such as short hospital stay, surgery performed under local anesthesia and sedation, early return to daily activities, and low rate of complications.

Needle-Guided Suture Technique for Lumbar Annular Fiber Closure in Microendoscopic Discectomy: A Technical Note and Case Series

BACKGROUND Annular fiber closure techniques have been proven effective in reducing short-term recurrence after discectomy. However, annular fiber closure devices are expensive and still fail at a low rate. We present a novel suture method, needle-guided annular closure suture (NGACS) that does not require a special device and can be performed for annular fiber closure following microendoscopic discectomy. MATERIAL AND METHODS Twenty-five patients who underwent treatment with NGACS were reviewed by analysis of the medical records. The clinical outcomes were assessed and compared preoperatively and immediately, 1, 6, and 12 months postoperatively. The parameters included the Visual Analog Scale (VAS)-back and VAS-leg scores and the Oswestry Disability Index (ODI). Midsagittal T2WI images were obtained to evaluate lumbar disc degeneration using the Pfirrmann grade. Additional adverse events were also recorded and tracked. RESULTS The VAS-back and VAS-leg scores and the ODI were significantly different at each follow-up time point (P<0.001), and improvements in pain and disability were maintained well during the follow-up period. Lumbar disc reherniation or other serious adverse events were not observed in this series. There was no significant difference between the initial and final Pfirrmann grades (Z=-1.414, P=0.157). The preoperative average disc height was 9.94±1.97 mm, and the disc height at 12 months after surgery was 9.14±1.88 mm. The average decrease in disc height was 8.11±3.36%. CONCLUSIONS This study demonstrates the feasibility and superior clinical outcomes of the NGACS technique. This method can be a good substitution when annular fiber closure devices are not available. Moreover, this technique can be easily popularized due to its low cost and few restrictions.

Comparison of the effectiveness and outcome of microendoscopic and open discectomy in patients suffering from lumbar disc herniation

BACKGROUND

The purpose of our study is to compare the outcomes and effectiveness of MED vs OLD for lumbar disc herniation.

OBJECTIVES

To identify the functional outcomes in terms of ODI score, VAS score complications in terms of intraoperative blood loss, use of general anesthesia, and morbidity in terms of total hospital stay between MED and OLD.

METHODS

In our randomized prospective study we analyzed 60 patients with clinical signs and symptoms with 2 weeks of failed conservative treatment plus MRI or CT scan findings of lumbar disc herniation who underwent MED and OLD. The study was undertaken from November 2017 to January 2019 at Guangzhou Medical University of Second Affiliated Hospital, department of orthopedic surgery in spinal Unit, Guangzhou, China. Patients were divided into 2 groups i.e. who underwent MED group and the OLD group then we compared the preoperative and postoperative ODI and VAS score, duration of total hospital stay, intraoperative blood loss, and operation time.

RESULTS

We evaluated 60 patients. Among them, 30 underwent MED (15 female and 15 male) and 30 underwent OLD 14 male 16 female. Surgical and anesthesia time was significantly shorter, blood loss and hospital stay were significantly reduced in patients having MED than OLD (<0.005). The improvement in the ODI in both groups was clinically significant and statistically (P < .005) at postoperative 1st day (with greater improvement in the MED group), at 6 weeks (P > .005), month 6 (>0.005) statistically no significant. The clinical improvement was similar in both groups. VAS and ODI scores improved significantly postoperatively in both groups. However, the MED group was superior to the OLD group with less time in bed, shorter operation time, less blood loss which is clinically and statistically significant (P < .05).

CONCLUSIONS

The standard surgical treatment of lumbar disc herniation has been open discectomy but there has been a trend towards minimally invasive procedures. MED for lumbar spine disc herniation is a well-known but developing field, which is increasingly spreading in the last few years. The success rate of MED is about approximately 90%. Both methods are equally effective in relieving radicular pain. MED was superior in terms of total hospital stay, morbidity, and earlier return to work and anesthetic exposure, blood loss, intra-op time comparing to OLD. MED is a safe and effective alternative to conventional OLD for patients with lumbar disc herniation.

Unilateral discectomy: outcomes, postoperative pain, complications

In low back pain management surgery is currently commonly used with a new technique called minimally invasive discectomy, while open discectomy is still preferable in many cases. In this regard, the efficacy of tubular discectomy (TD) were compared with conventional standard lumbar disc procedure (conventional microdiscectomy). This study was performed as a clinical trial conducted on patients who were under TD and conventional microdiscectomy using unilateral retractor at Bou Ali, Mehrad, Laleh Hospitals during the years 2001 to 2017. The pain score was determined based on the use of Visual Analogue Scale (VAS). The Roland Morris Disability Questionnaires (RMQ) and mean Oswestry disability index (ODI) were also calculated. Our findings revealed that the two groups were similar in terms of demographic characteristics (age, sex, body mass index, etc.) (p> 0.05). The findings indicated the superiority of TD over the classic approach. The mean scores of ODI in conventional microdiscectomy and TD groups were reported as 12.53 ± 7.09 and 9.51 ± 7.83, respectively. ODI revealed that patients with TD surgery had less disability in lifting objects, sitting, standing, and traveling. In the conventional microdiscectomy group, 12 (20%) patients were affected by complications of surgery, but no complication was reported in any patient with TD (p = 0.000). The mean index of Roland Morris disability in the conventional microdiscectomy and TD groups were estimated to be 6.033 ± 2.98 and 3.73 ± 3.25 (p = 0.000). However, both groups did not differ in terms of visual scores for pain and relapse (p > 0.05). Our study demonstrates that disease relapse within 6 months after the surgery, the RMQ and the ODI values were significantly better in TD than the other group.

A Review of Lumbar Radiculopathy, Diagnosis, and Treatment

We review the epidemiology, etiology, symptomatology, clinical presentation, anatomy, pathophysiology, workup, diagnosis, non-surgical and surgical management, postoperative care, outcomes, long-term management, and morbidity of lumbar radiculopathy. We review when outpatient conservative management is appropriate and "red flag" warning symptoms that would necessitate an emergency evaluation. Diagnostic modalities, including magnetic resonance imaging (MRI), computerized tomography (CT), contrast myelogram, electromyogram (EMG), and nerve conduction velocity (NCV), are involved in the diagnosis and decision-making are discussed. Treatment of lumbar radiculopathy requires a multimodal and multispecialty team. We review indications for the involvement of other professionals, including physical therapy (PT), occupational therapy (OT), physical and rehabilitation medicine (PMR), and pain management.

Microendoscopic discectomy for lumbar disc herniations

Introduction:

Lumbar disc herniation is one of the main causes of discogenic low back pain and reported to affect 60%–80% of people during their lifetime. The two main surgical modalities for intervertebral disc surgery are standard open discectomy and minimally invasive discectomy which include percutaneous endoscopic lumbar discectomy and microendoscopic discectomy (MED). We report our experience with the same technique of MED to evaluate the efficacy of MED for lumbar disc pathology.

Aims and Objectives:

The aims and objectives were to study the efficacy, advantages, and associated limitations and complications of MED in lumbar disc herniations.

Materials and Methods:

This study was carried out on 300 patients who had single-level herniated disc. The procedure was done by Microscopic Endoscopic Tubular Retraction System. Preoperative assessment of Visual Analog Scale (VAS) and modified Suezawa and Schreiber (MSS) clinical scoring system was documented 1 day prior to surgery. Postoperative results were determined to be excellent, good, fair, or poor according to MacNab criteria and also evaluated by MSS clinical scoring system on postoperative day 7 and after 6 months.

Results:

A total of 187 patients were males and 113 patients were females and a majority of patients were in the age group of 31–40 years. A total of 192 patients had disc herniations at L4–L5 level. The mean operative time was 82 min and the mean hospital stay was 5.3 days. Eighteen cases (6%) developed postoperative complications including discitis, dysesthesia, recurrent prolapsed intervertebral disc, residual disc, dural tear, and nerve root injury. Mean preoperative VAS score was 8.7 and the mean postoperative VAS scores at postoperative day 7 and at 6 months were 2.25 and 1.12, respectively. The mean preoperative MSS score was 3.27 and the MSS scores at postoperative day 7 and at 6 months were 7.42 and 8.2, respectively. The overall successful outcome of the endoscopic discectomy after 6-month follow-up on the basis of VAS improvement percentage was 87.6%, MSS scoring percentage was 91.6%, and MacNab scoring percentage was 92.67%.

Conclusion:

MED is a safe and effective technique. It offers decreased blood loss, shorter operative time, shorter in-hospital stay, decreased need for pain medication, decreased rate of infection, and a shorter return to work time. Limitations of this technique include a learning curve which is related to surgery time, complications, conversion to open procedures, and recurrent disc herniation.

[Surgical treatment of pain syndrome in lumbar spine in patients with obesity]

AIM

To analyze the reduction of pain severity, time of surgery, intraoperative blood loss, incidence of unintentional lesion of dura mater, infectious complications and hospital-stay after lumbar microdiscectomy.

MATERIAL AND METHODS

The study included 104 patients aged 24-58 years (37 men and 67 women, mean age 45 years) who underwent lumbar microdiscectomy within January 2015 - June 2016. The main and control groups consisted of 48 and 56 patients with and without obesity respectively. In all cases lumbar microdiscectomy was made. Pain syndrome was assessed by visual analogue scale and Oswestry questionnaire.

RESULTS

In 6 weeks, 6 and 12 months after surgery significant improvement of both lumbar and leg pain was observed. Significantly reduced pain was stable and similar in both groups within follow-up although there was a tendency to increased pain in long-term period in group 1. Blood loss and infections were slightly higher in obese group while surgery time and hospital-stay were significantly higher in these patients.

CONCLUSION

Features of patients with excessive body weight should be considered prior to elective surgery. Probably, implants are advisable to stabilize spinal motion segment and improve the outcomes among patients with excessive body weight.

Feasibility of endoscopic discectomy by inter laminar approach at a high volume tertiary public hospital in a developing country

BACKGROUND

Surgical treatment for lumbar disc herniation consists of discectomy performed either open or minimally invasive techniques. Endoscopic discectomy using the tubular retractor is been increasingly used as it gives advantage of smaller incision, less tissue injury and faster recovery. The aim of this study was to check its feasibility and learning curve at a tertiary public sector hospital with a large volume load (more than 50 spine surgeries per month) with treatment provided free of cost.

METHODS

Eighty patients underwent endoscopic discectomy using tubular retractor were prospectively followed for a period of 12 months. All patients included were having disc herniation at a single level after appropriate conservative trial of 6 weeks. Patients with segmental instability or previous spine surgery were excluded. All were operated by a single senior orthopaedic surgeon. Duration of surgery, blood loss, and day of mobilization, complications and duration of hospitalisation were noted. VAS for pain, Oswestry Disability Index, SF 12 and modified MacNab criteria were used to assess the functional outcome.

RESULTS

Mean age of patients was 34.9 years (range 17 to 72 years) with sex ratio of 2.6:1. The mean VAS score improved from 8 to 1.1, Oswestry Disability Index from 52 to 20 and SF 12 scores (MCS/PCS) from 34/43 to 49.2/56. According to modified MacNab criteria there were 77.5% excellent, 13.75% good, 7.5% fair and 1.25% poor cases. Average surgical duration was 48.75 min and blood loss was 32.13 mL. There were 3 dural tears, 1 infection, 2 recurrences and 1 sensory radiculopathy.

CONCLUSIONS

Endoscopic discectomy using tubular retractor has a potential to become a gold standard in catering this patient groups. It has great feasibility and shows equivalent results to all other techniques with lesser learning curve being an added advantage.

Percutaneous endoscopic lumbar discectomy: Results of first 100 cases

BACKGROUND

Lumbar disc herniation is a major cause of back pain and sciatica. The surgical management of lumbar disc prolapse has evolved from exploratory laminectomy to percutaneous endoscopic discectomy. Percutaneous endoscopic discectomy is the least invasive procedure for lumbar disc prolapse. The aim of this study was to analyze the clinical outcome, quality of life, neurologic function, and complications.

MATERIALS AND METHODS

One hundred patients with lumbar disc prolapse who were treated with percutaneous endoscopic discectomy from May 2012 to January 2014 were included in this retrospective study. Clinical followup was done at 1 month, 3 months, 6 months, 1 year, and at yearly interval thereafter. The outcome was assessed using modified Macnab's criteria, visual analog scale, and Oswestry Disability Index.

RESULTS

The mean followup period was 2 years (range 18 months - 3 years). Transforaminal approach was used in 84 patients, interlaminar approach in seven patients, and combined approach in nine patients. An excellent outcome was noted in ninety patients, good outcome in six patients, fair result in two patients, and poor result in two patients. Minor complications were seen in three patients, and two patients had recurrent disc prolapse. Mean hospital stay was 1.6 days.

CONCLUSIONS

Percutaneous endoscopic lumbar discectomy is a safe and effective procedure in lumbar disc prolapse. It has the advantage that it can be performed on a day care basis under local anesthesia with shorter length of hospitalization and early return to work thus improving the quality of life earlier. The low complication rate makes it the future of disc surgery. Transforaminal approach alone is sufficient in majority of cases, although 16% of cases required either percutaneous interlaminar approach or combined approach. The procedure definitely has a learning curve, but it is acceptable with adequate preparations.

Burden of Surgical Site Infections Associated with Select Spine Operations and Involvement of Staphylococcus aureus

BACKGROUND

Spine operations may be indicated for treatment of diseases including vertebral injuries, degenerative spinal conditions, disk disease, spinal misalignments, or malformations. Surgical site infection (SSI) is a clinically important complication of spine surgery. Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus (MRSA), is a leading cause of post-spinal SSIs.

METHODS

PubMed and applicable infectious disease conference proceedings were searched to identify relevant published studies. Overall, 343 full-text publications were screened for epidemiologic, mortality, health care resource utilization, and cost data on SSIs associated with specified spine operations.

RESULTS

Surgical site infection rates were identified in 161 studies from North America, Europe, and Asia. Pooled average SSI and S. aureus SSI rates for spine surgery were 1.9% (median, 3.3%; range, 0.1%-22.6%) and 1.0% (median, 2.0%; range, 0.02%-10.0%). Pooled average contribution of S. aureus infections to spinal SSIs was 49.3% (median, 50.0%; range, 16.7%-100%). Pooled average proportion of S. aureus SSIs attributable to MRSA was 37.9% (median, 42.5%; range, 0%-100%). Instrumented spinal fusion had the highest pooled average SSI rate (3.8%), followed by spinal decompression (1.8%) and spinal fusion (1.6%). The SSI-related mortality rate among spine surgical patients ranged from 1.1%-2.3% (three studies). All studies comparing SSI and control cohorts reported longer hospital stays for patients with SSIs. Pooled average SSI-associated re-admission rate occurring within 30 d from discharge ranged from 20% to 100% (four studies). Pooled average SSI-related re-operation rate was 67.1% (median, 100%; range, 33.5%-100%). According to two studies reporting direct costs, spine surgical patients incur approximately double the health care costs when they develop an SSI.

CONCLUSIONS

Available published studies demonstrate a clinically important burden of SSIs related to spine operations and the substantial contribution of S. aureus (including MRSA). Preventive strategies aimed specifically at S. aureus SSIs could reduce health care costs and improve patient outcomes for spine operations.

Comparison of safety and efficiency of microendoscopic discectomy with automatic nerve retractor and with nerve hook

This study compares the safety and efficiency of two techniques in microendoscopic discectomy (MED) for lumbar disc herniation. The two techniques are MED with automatic nerve retractor and MED with nerve hook which had been widely used for many years. The former involves a newly developed MED device which contains three parts to protect nerve roots during operation. Four hundred and twenty-eight patients underwent MED treatments between October 2010 and September 2015 were recruited and randomized to either intraoperative utilization of automatic nerve retractor (n = 315, group A) or application of nerve hook during surgery (n = 113, group B). Operation time and intraoperative bleeding volume were evaluated. Simultaneously, Visual Analogue Scales (VAS) and muscle strength grading were performed preoperatively, and 1, 2, 3 days, 1, 2 weeks, 3 and 6 months postoperatively. No dramatic difference of pain intensity was observed between the two groups before surgery and 6 months after surgery (P > 0.05). The operation time was shorter in group A (30.30 ± 1.89 min) than that in group B (59.41 ± 3.25 min). Group A (67.83 ± 13.14 ml) experienced a significant decrease in the amount of blood loss volume when compared with group B (100.04 ± 15.10 ml). There were remarkable differences of VAS score and muscle strength grading after postoperative 1, 2, 3 days, 1, 2 weeks and 3 months between both groups (P ≤ 0.05). MED with automatic nerve retractor effectively shortened operation time, decreased the amount of bleeding, down-regulated the incidence of nerve traction injury.

Microdiscectomy or tubular discectomy: Is any of them a better option for management of lumbar disc prolapse

Objectives:

Various types of minimally invasive techniques have been developed for the treatment of lumbar disc herniation. The original laminectomy was refined into microdiscectomy (MD). MD is the gold standard in management of lumbar disc herniation and is used as a yardstick for comparison with newer procedures such as tubular discectomy. So far, no studies have been reported in Indian population comparing tubular discectomy and microdiscectomy. The aim of this study was to compare immediate postoperative and 1-year outcome of patients undergoing tubular discectomy with those undergoing MD and to evaluate the learning curve as well as complication rates of tubular discectomy.

Materials and Methods:

Forty-six patients of MD and 102 (48 early and 54 late) patients of tubular discectomy (TD) were operated at Indian Spinal Injuries Centre, which is a tertiary level center between July 2009 and January 2012. They were studied for the following data: Baseline characteristics, visual analog scale (VAS) for leg pain and back pain, Oswestry Disability Index (ODI) scores, length of hospital stay, time taken to return to work, duration of surgery, intra- and post-operative complications, and reoperation rates.

Results:

The VAS score for leg pain, back pain, and ODI scores showed improvement in both groups during the 1^st year after surgery. Time taken to return to work and mean hospital stay was shorter in case of TD as compared to MD group. The mean duration of surgery was 34 min shorter for conventional MD. The incidence of dural tear was 6.5% in MD group and 10.4% in early TD and decreased to 7.4% in late TD group.

Conclusion:

This study revealed that rate of recovery is significantly faster for TD as compared to conventional MD. In contrast, we encountered fewer complications in MD approach as compared to TD which although were not statistically significant and which also decreased as we gained experience.

Intervertebral Fusion with Mobile Microendoscopic Discectomy for Lumbar Degenerative Disc Disease

The aim of this article is to introduce a technique for lumbar intervertebral fusion that incorporates mobile microendoscopic discectomy (MMED) for lumbar degenerative disc disease. Minimally invasive transforaminal lumbar interbody fusion is frequently performed to treat degenerative diseases of the lumbar spine; however, the scope of such surgery and vision is limited by what the naked eye can see through the expanding channel system. To expand the visual scope and reduce trauma, we perform lumbar intervertebral fusion with the aid of a MMED system that provides a wide field through freely tilting the surgical instrument and canals. We believe that this technique is a good option for treating lumbar degenerative disc disease that requires lumbar intervertebral fusion.

Results of arthrospine assisted percutaneous technique for lumbar discectomy

BACKGROUND

Avaialable minimal invasive arthro/endoscopic techniques are not compatible with 30 degree arthroscope which orthopedic surgeons uses in knee and shoulder arthroscopy. Minimally invasive "Arthrospine assisted percutaneous technique for lumbar discectomy" is an attempt to allow standard familiar microsurgical discectomy and decompression to be performed using 30° arthroscope used in knee and shoulder arthroscopy with conventional micro discectomy instruments.

MATERIALS AND METHODS

150 patients suffering from lumbar disc herniations were operated between January 2004 and December 2012 by indiginously designed Arthrospine system and were evaluated retrospectively. In lumbar discectomy group, there were 85 males and 65 females aged between 18 and 72 years (mean, 38.4 years). The delay between onset of symptoms to surgery was between 3 months to 7 years. Levels operated upon included L1-L2 (n = 3), L2-L3 (n = 2), L3-L4 (n = 8), L4-L5 (n = 90), and L5-S1 (n = 47). Ninety patients had radiculopathy on right side and 60 on left side. There were 22 central, 88 paracentral, 12 contained, 3 extraforaminal, and 25 sequestrated herniations. Standard protocol of preoperative blood tests, x-ray LS Spine and pre operative MRI and pre anaesthetic evaluation for anaesthesia was done in all cases. Technique comprised localization of symptomatic level followed by percutaneous dilatation and insertion of a newly devised arthrospine system devise over a dilator through a 15 mm skin and fascial incision. Arthro/endoscopic discectomy was then carried out by 30° arthroscope and conventional disc surgery instruments.

RESULTS

Based on modified Macnab's criteria, of 150 patients operated for lumbar discectomy, 136 (90%) patients had excellent to good, 12 (8%) had fair, and 2 patients (1.3%) had poor results. The complications observed were discitis in 3 patients (2%), dural tear in 4 patients (2.6%), and nerve root injury in 2 patients (1.3%). About 90% patients were able to return to light and sedentary work with an average delay of 2 weeks and normal physical activities after 2 months.

CONCLUSION

Arthrospine system is compatible with 30° arthroscope and conventional micro-discectomy instruments. Technique minimizes approach related morbidity and provides minimal access corridor for lumbar discectomy.

Lumbar Endoscopic Microdiscectomy: Where Are We Now? An Updated Literature Review Focused on Clinical Outcome, Complications, and Rate of Recurrence

Endoscopic disc surgery (EDS) for lumbar spine disc herniation is a well-known but developing field, which is increasingly spreading in the last few years. Rate of recurrence/residual, complications, and outcomes, in comparison with standard microdiscectomy (MD), is still debated and need further data. We performed an extensive review based on the last 6 years of surgical series, systematic reviews, and meta-analyses reported in international, English-written literature. Articles regarding patients treated through endoscopic transforaminal or interlaminar approaches for microdiscectomy (MD) were included in the present review. Papers focused on endoscopic surgery for other spinal diseases were not included. From July 2009 to July 2015, we identified 51 surgical series, 5 systematic reviews, and one meta-analysis reported. In lumbar EDS, rate of complications, length of hospital staying, return to daily activities, and overall patients' satisfaction seem comparable to standard MD. Rate of recurrence/residual seems higher in EDS, although data are nonhomogeneous among different series. Surgical indication and experience of the performing surgeon are crucial factors affecting the outcome. There is growing but still weak evidence that lumbar EDS is a valid and safe alternative to standard open microdiscectomy. Statistically reliable data obtained from randomized controlled trials (better if multicentric) are desirable to further confirm these results.

Microendoscopy-assisted minimally invasive transforaminal lumbar interbody fusion for lumbar degenerative disease: short-term and medium-term outcomes

OBJECTIVE

To evaluate short-term and medium-term outcomes of microendoscopy-assisted minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and open TLIF for lumbar degenerative disease.

METHODS

In this prospective, randomized control study, 50 cases received microendoscopy-assisted MIS-TLIF (MIS group), while another well-matched 50 cases accepted open TLIF (open group). Parameters between both groups, including surgical duration, intraoperative blood loss and radiologic exposure, postoperative analgesic usage and ambulatory time, visual analogue scale (VAS) for back and leg, functional scores, self-evaluation of surgical outcome (modified MacNab criteria), interbody fusion rate, adjacent segment degeneration (ASD) rate, as well as complication incidence were compared at 1 month and 24 months postoperatively.

RESULTS

Intraoperative blood loss and postoperative analgesic usage were significantly reduced in MIS group (P<0.05). Patients undergoing microendoscopy-assisted MIS-TLIF were able to ambulate earlier postoperatively than those receiving open TLIF (P<0.05). However, it showed prolonged surgical duration and enhanced radiologic exposure in MIS group (P<0.05). At 1 month postoperatively, MIS group was associated with more improvement of VAS and functional scores compared with open group (P<0.05). While at 24 months postoperatively, both groups revealed similar VAS and functional scores (P>0.05). Excellent and perfect scale rating by modified MacNab criteria, interbody fusion rate, ASD rate and complication incidence between both groups were nearly the same (P>0.05).

CONCLUSIONS

Microendoscopy-assisted MIS-TLIF owns advantages of less iatrogenic injury, decreased blood loss, reduced analgesic usage and earlier rehabilitation, while it has drawbacks of more surgical duration and radiologic exposure. It is superior than open TLIF in terms of short-term clinical outcomes and has similar medium-term clinical outcomes.

What were the advantages of microendoscopic discectomy for lumbar disc herniation comparing with open discectomy: a meta-analysis?

The purpose of this study was to compare the safety and efficacy of micro-endoscopic discectomy (MED) and open discectomy (OD) for lubmar disc herniation (LDH). Randomised controlled trials (RCTs) comparing MED with OD for LDH were searched comprehensively in PubMed, EMBASE, the Cochrane Library. Relevant studies retrieved, data extracted and the quality of included studies were independently performed by two authors. RevMan software (Version 5.2.0) was used to analyse and synthesis relevant data of the included studies. Nine RCTs involving 774 patients were obtained and reported the relevant outcome measures. Compared with OD group, there were significant difference in the general operation indicators including operation time, blood loss, site of incision, hospital stay and time of return to work, biochemical indexes including C-reactive protein (CRP) and interleukin-6 (IL-6) in MED group. Meanwhile, there were no difference in effective rate, complication including total complications, dural leaks occurred and recurrence of the disc herniation, compared MED group with OD group. MED had slighter trauma, milder blood loss and shorter healing time than OD. The results demonstrated MED has great efficacy and safety comparable to OD. So we think that MED can be used routinely for LDH patients, especially the patients of old and intolerable major surgery. Meanwhile, it is necessary for surgeon to master indication and contraindication of MED and improve the operative technique.