Comparison of the clinical efficacy of percutaneous transforaminal endoscopic discectomy and traditional laminectomy in the treatment of recurrent lumbar disc herniation.

ABSTRACT: A few years ago, percutaneous transforaminal endoscopic discectomy (PTED) began to prevail in clinical treatment of recurrent lumbar disc herniation (RLDH), whereas traditional laminectomy (TL) was treated earlier in RLDH than PTED. This study aimed to compare the clinical efficacy of PTED and TL in the treatment of RLDH.Between November 2012 and October 2017, retrospective analysis of 48 patients with RLDH who were treated at the Cancer Hospital, Chinese Academy of Sciences, Hefei and Department of Orthopaedics, Second Affiliated Hospital of Anhui Medical University. Perioperative evaluation indicators included operation time, the intraoperative blood loss, length of incision and hospitalization time. Clinical outcomes were measured preoperatively, and at 1 days, 3 months, and 12 months postoperatively. The patients' lower limb pain was evaluated using Oswestry disability index (ODI) and visual analog scale (VAS) scores. The ODI is the most widely-used assessment method internationally for lumbar or leg pain at present. Every category comprises 6 options, with the highest score for each question being 5 points. higher scores represent more serious dysfunction. The VAS is the most commonly-used quantitative method for assessing the degree of pain in clinical practice. The measurement method is to draw a 10 cm horizontal line on a piece of paper, 1 end of which is 0, indicating no pain, which the other end is 10, which means severe pain, and the middle part indicates different degree of pain.Compared with the TL group, the operation time, postoperative bed-rest time, and hospitalization time of the PTED group were significantly shorter, and the intraoperative blood loss was also reduced. These differences were statistically significant (P < .01). There were no significant differences in VAS or ODI scores between the two groups before or after surgery (P > .05).PTED and TL have similar clinical efficacy in the treatment of RLDH, but PTED can shorten the operation time, postoperative bed-rest time and hospitalization time, and reduce intraoperative blood loss, so the PTED is a safe and effective surgical method for the treatment of RLDH than TL, but more randomized controlled trials are still required to further verify these conclusions.

Percutaneous endoscopic lumbar discectomy compared with other surgeries for lumbar disc herniation: A meta-analysis.

OBJECTIVE: This meta-analysis was performed to investigate whether percutaneous endoscopic lumbar discectomy (PELD) had a superior effect than other surgeries in the treatment of patients with lumbar disc herniation (LDH). METHOD: We searched PubMed, Embase, and Web of Science through February 2018 to identify eligible studies that compared the effects and complications between PELD and other surgical interventions in LDH. The outcomes included success rate, recurrence rate, complication rate, operation time, hospital stay, blood loss, visual analog scale (VAS) score for back pain and leg pain, 12-item Short Form Health Survey (SF12) physical component score, mental component score, Japanese Orthopaedic Association Score, Oswestry Disability Index. A random-effects or fixed-effects model was used to pool the estimate, according to the heterogeneity among the included studies. RESULTS: Fourteen studies (involving 2,528 patients) were included in this meta-analysis. Compared with other surgeries, PELD had favorable clinical outcomes for LDH, including shorter operation time (weight mean difference, WMD=-18.14 minutes, 95%CI: -25.24, -11.05; P < .001) and hospital stay (WMD = -2.59 days, 95%CI: -3.87, -1.31; P < .001), less blood loss (WMD = -30.14 ml, 95%CI: -43.16, -17.13; P < .001), and improved SF12- mental component score (WMD = 2.28, 95%CI: 0.50, 4.06; P = .012)) and SF12- physical component score (WMD = 1.04, 95%CI: 0.37, 1.71; P = .02). However, it also was associated with a significantly higher rate of recurrent disc herniation (relative risk [RR] = 1.65, 95%CI: 1.08, 2.52; P = .021). There were no significant differences between the PELD group and other surgical group in terms of success rate (RR = 1.01, 95%CI: 0.97, 1.04; P = .733), complication rate (RR = 0.86, 95%CI: 0.63, 1.18; P = .361), Japanese Orthopaedic Association Score score (WMD = 0.19, 95%CI: -1.90, 2.27; P = .861), visual analog scale score for back pain (WMD = -0.17, 95%CI: -0.55, 0.21; P = .384) and leg pain (WMD = 0.00, 95%CI: -0.10, 0.10; P = .991), and Oswestry Disability Index score (WMD = -0.29, 95%CI: -1.00, 0.43; P = .434). CONCLUSION: PELD was associated with better effects and similar complications with other surgeries in LDH. However, it also resulted in a higher recurrence rate. Considering the potential limitations in the present study, further large-scale, well-performed randomized trials are needed to verify our findings.

Learning curve of percutaneous endoscopic transforaminal lumbar discectomy by a single surgeon.

ABSTRACT: To evaluate the learning curve of percutaneous endoscopic transforaminal lumbar discectomy (PETLD) from the novice stage to the proficient stage, we performed retrospective study for patients with lumbar disc herniation who underwent PETLD performed by a single surgeon and evaluated the surgeon's learning curve and the effect of surgical proficiency on outcomes.A total of 48 patients who underwent PETLD at the lower lumbar level (L3-S1) with a minimum 1-year follow-up were enrolled. The learning curve of the surgeon was assessed using cumulative study of operation time and linear regression analyses to reveal the correlation between operation time and case series number.Because the cutoff of familiarity was 25 cases according to the cumulative study of operation time, the patients were allocated into two groups: early group (n = 25) and late group (n = 23). The clinical, surgical, and radiological outcomes were retrospectively evaluated and compared between the two groups.According to linear regression analyses, the operation time was obtained using the following formula: operation time (minutes) = 69.925-(0.503 × [case number]) (P < .001).As expected, the operation time was significantly different between the two groups (mean 66.00 ±â€Š11.37 min in the early group vs 50.43 ±â€Š7.52 min in the late group, P < .001). No differences were found between the two groups in demographic data and baseline characteristics. Almost all clinical outcomes (including pain improvement and patient satisfaction), surgical outcomes (including failure, recurrence, and additional procedure rates), and radiological outcomes (including change of disc height and sagittal angles) did not differ between the two groups.However, the late group demonstrated a more favorable postoperative volume index of the remnant disc (362.91 mm3 [95% confidence interval, 272.81-453.02] in the early group vs 161.14 mm3 [95% confidence interval, 124.31-197.97] in the late group, P < .001), and a lower complication rate related to exiting nerve root (16.0% in the early group vs 0% in the late group, P = .045).The learning curve of PETLD is not as difficult as that of other minimally invasive spine surgery technique. Although the overall outcomes were not different between the groups, the risks of incomplete decompression and exiting root injury-related complication were higher in the novice stage.

Treatment of cervical spondylotic radiculopathy with posterior percutaneous endoscopic cervical discectomy: Short-term outcomes of 24 cases.

To determine the short-term clinical outcomes of single-segment cervical spondylotic radiculopathy treated with posterior percutaneous endoscopic cervical discectomy (PPECD).Data of a total of 24 patients who underwent PPECD and local anesthesia for single-level segmental cervical spondylotic radiculopathy between March 2016 and December 2017 were reviewed. The Japanese Orthopaedic Association, visual analog scale (VAS), and neck disability index scores at preoperative 1 day, postoperative 1 day, 1 week, 1 month, 3 months, 6 months, and 1 year were recorded. The modified MacNab criteria at the last follow-up were re-recorded for the evaluation of clinical effectiveness.All operations were successfully completed under endoscopic guidance. No patient showed spinal cord, nerve root, vascular injuries, dural tears or other complications. The postoperative VAS scores of the arm and neck were significantly reduced compared with the preoperative VAS scores (P < .05), while postoperative the Japanese Orthopaedic Association scores were significantly increased (P < .05). The postoperative neck disability index scores were significantly reduced compared with preoperative scores (P < .05). The modified MacNab criteria at the last follow-up showed 16 excellent cases, 8 good cases, 0 fine cases, and 0 poor cases. Postoperative magnetic resonance imaging and cervical 3-dimensional computed tomography reconstruction showed that the intervertebral disc was adequately resected and the nerve root was not under compression.PPECD is safe and effective for the treatment of single-segment cervical spondylotic radiculopathy.

Percutaneous endoscopic lumbar discectomy for lumbar disc herniation as day surgery - short-term clinical results of 235 consecutive cases.

Many studies have reported the good outcomes of percutaneous endoscopic lumbar discectomy (PELD) for the treatment of lumbar disc herniation (LDH). However, the majority of published studies on PELD showed an average hospital stay of 2 to 5 days. Thus, the purpose of this retrospective study was to evaluate and compare the clinical outcomes of patients undergoing PELD for LDH as day surgery with the outcomes of patients managed as inpatients.A total of 402 patients who underwent PELD for single-level LDH were included. The visual analog scale score (VAS) for leg and back pain, Oswestry Disability Index (ODI) score, and Macnab criteria were evaluated preoperatively and at 2 years postoperatively (final follow-up). Operation time, duration of hospital stay, cost, postoperative complications, and the rates of and reasons for delayed discharge and readmission were recorded and analyzed.The mean operative time was 45.8 ±â€Š8.4 minutes in the PELD-A (nonday surgery mode) group and 41.3 ±â€Š8.7 minutes in the PELD-D (day surgery mode) group (P = .63). The average duration of hospital stay was 2.8 ±â€Š1.1 days in the PELD-A group and 3.2 ±â€Š0.9 hours in the PELD-D group (P < .001). The average hospitalization expenses of the PELD-A and PELD-D groups were 28,090 ±â€Š286 RMB and 24,356 ±â€Š126 RMB (P = .03), respectively. In both groups, the mean VAS and ODI scores improved significantly postoperatively compared with the preoperative scores. The satisfactory result rate was 89.8% in the PELD-D group and 91.0% in the PELD-A group, without a significant difference (P = .68). The delayed discharge rate in the PELD-A and PELD-D groups was 8.20% and 8.43%, respectively (P = .93). The main reasons for delayed discharge were dysesthesia, neurologic deficit, nausea, headache and residential distance from the hospital. The overall readmission rates were 5.99% and 5.53% in the PELD-A and PELD-D groups, respectively (P = .85). The most common reasons for readmission were reherniation, sequestered herniation and pain.In conclusion, PELD is safe and effective for the treatment of LDH and can reduce medical costs as day surgery, and it thus warrants increased attention.

Discharge Disposition After Anterior Cervical Discectomy and Fusion.

OBJECTIVE: Age and comorbidity burden of patients going anterior cervical discectomy and fusion (ACDF) have increased significantly over the past 2 decades, resulting in increased expenditures. Non-home discharge after ACDF contributes to increased direct and indirect costs of postoperative care. The purpose of this study was to identify independent prognostic factors for discharge disposition in patients undergoing ACDF. METHODS: A retrospective review was conducted at 5 medical centers to identify patients undergoing ACDF for degenerative conditions. The primary outcome was non-home discharge. Additional outcomes considered included discharge to rehabilitation and home discharge with services. Bivariate and multivariable analyses were used to identify independent prognostic factors for non-home discharge. RESULTS: Of 2070 patients undergoing ACDF, 114 (5.5%) had non-home discharge and 63 (3.0%) had discharge to inpatient rehabilitation. Factors independently associated with non-home discharge included older age, marital status, Medicare insurance, Medicaid insurance, previous spine surgery, myelopathy, preoperative comorbidities (hemiplegia/paraplegia, congestive heart failure, cerebrovascular accident), anemia, and leukocytosis. C-statistic for the overall model was 0.85. Results were relatively similar for patients younger than the age of 65 years as well as for discharge to inpatient rehabilitation and discharge home with services. CONCLUSIONS: Numerous sociodemographic and clinical characteristics influence the risk of non-home discharge and discharge to inpatient rehabilitation in patients undergoing ACDF. Policy makers and payers should consider these factors when determining appropriate preoperative adjustment for risk-based reimbursements.

Percutaneous plasma laser disc coagulation and navigable ablation decompression in the treatment of cervical disc herniation: a single center experience

Background/aim: We aimed to compare the effectivity of percutaneous disc coagulation therapy (PDCT) and navigable ablation decompression treatment (L-DISQ) in patients who were diagnosed with cervical disc herniation. Materials and methods: Visual analog scale (VAS) and Neck Pain Index (NPI) scores were recorded initially and at the 1st, 3rd, 6th, and 12th months after the procedures. Patient Satisfaction Scale (PSS) scores were recorded 12 months after the procedures Results: Mean VAS scores were 7.55 and 3.1 points in the PDCT group and 7.6 and 3.00 points in the L-DISQ group; mean NPI scores were 34.2 and 20.75 points in the PDCT group and and 34.1 and 20.4 points in the L-DISQ group initially and at the 12th month. When compared between months, there was a significant decrease in time-dependent VAS and NPI scores in both PDCT and L-DISQ groups (P = 0.001). Some complications included esophageal, vascular, and neural injuries; hoarseness; Horner syndrome; infections; dural puncture; and muscle spasm. The only difference between groups was the rate of cervical spasm within 1 month after the procedure: 75% in the PDCT group and 15% in the L-DISQ group. Conclusion: The diameter of the canal of the cervical vertebrae is narrower than of the lumbar and thoracic regions; therefore, the smaller part of the disc may be sufficient to create clinical signs. The response to decompression therapies is faster in the case of cervical percutaneous procedures that are performed correctly. Proper patient selection and practitioner's experience are important in the treatment success

Percutaneous endoscopic discectomy in adolescent lumbar disc herniation: a 3- to 5-year study.

OBJECTIVEThe authors sought to investigate the efficiency of percutaneous endoscopic discectomy (PED) in adolescent patients with lumbar disc herniation (LDH), compare PED outcomes in adolescent patients with those in young adult LDH patients as controls, and discuss relevant technical notes.METHODSThis was a retrospective study involving 19 adolescent LDH patients (age > 13 and < 18 years, 20 discectomies) and 38 young adults (age < 40 years, 38 discectomies) who also had LDH and were matched to the adolescent group for sex and body mass index. The combined cohort included 51 male patients (89.5%) and 6 female patients (10.5%), with an average age of 26.7 years (range 14-39 years). The operated levels included L3-4 in 1 patient (1.7%), L4-5 in 22 patients (37.9%), and L5-S1 in 35 patients (60.4%). Two adolescents (10.5%) exhibited apophyseal ring separation and one (5.3%) had had previous PED. All patients underwent PED under local anesthesia. Outcomes were evaluated through a visual analog scale (VAS), the Japanese Orthopaedic Association (JOA) scoring system, and the modified MacNab grading system.RESULTSThe mean duration of follow-up was 41.7 months (range 36-65 months). The outcomes in adolescents were satisfactory and comparable with previously reported outcomes of microsurgical discectomy (MD) and conventional open discectomy (COD). The adolescent patients had a faster and better recovery course than the adult patients (p < 0.01). One adolescent patient (5.3%) exhibited recurrence and 2 adults (5.3%) experienced transient dysesthesia; the complication rates were comparable in the 2 age groups (p = 0.47). Prolonged duration of symptoms (p < 0.01) and disc degeneration (p = 0.01) were correlated with lower postoperative JOA values; patients with extrusions had higher postoperative JOA values than those with protrusions (p = 0.01).CONCLUSIONSPED may yield favorable results in the treatment of adolescent LDH in terms of short- to medium-term follow-up; restricted discectomy and a conservative rehabilitation program might be advisable. Further long-term studies are warranted to address this rare disease entity.

Percutaneous endoscopic interlaminar discectomy of L5-S1 disc herniation: a comparison between intermittent endoscopy technique and full endoscopy technique.

BACKGROUND: Percutaneous endoscopic laminar discectomy is a typical minimally invasive discectomy operation that is classified into the percutaneous endoscopic transforaminal discectomy and the percutaneous endoscopic interlaminar discectomy. Based on whether the surgeon chooses to deal with the ligamentum flavum under endoscope guidance, percutaneous endoscopic discectomy by the interlaminar approach can be performed with a full endoscope technique with the intermittent endoscope technique. To our knowledge, there is no study comparing these two techniques in regard to their surgical effects and advantages. Therefore, we conducted this study to compare the cost, safety, and efficacy between the intermittent endoscopy technique and full endoscopy technique of endoscopic interlaminar lumbar discectomy at the L5-S1 level. METHODS: From September 2014 to March 2015, a total of 126 patients with radiculopathy due to L5-S1 disc herniation who were treated by a full endoscopy technique (65 patients) or intermittent endoscopy technique (61 patients) were included. Relevant data, such as duration time of the operation, hospitalization expenses, postoperative bed rest time, length of hospitalization, and complication rates, were recorded. Clinical outcomes were assessed by the visual analog scale score, modified MacNab criteria, and Oswestry disability index. RESULTS: In the full endoscope (FE) group, the mean duration time of surgery was 75.0 ± 11.9 min. The postoperative bed rest time was 6.5 ± 1.1 h, length of hospitalization was 3.8 ± 1.1 days, and complication rate was 7.69%. In the intermittent endoscopy (IE) group, the mean duration time of surgery was 43.0 ± 16.4 min. The postoperative bed rest time was 5.0 ± 1.1 h, length of hospitalization was 3.6 ± 1.2 days, and complication rate was 6.60%. The average hospitalization expenses of the FE group and IE group, respectively, were 32,069 ± 1086 RMB and 22,665 ± 899 RMB. There were significant differences in the surgical duration and hospitalization expenses (P < 0.01), but no differences between the two groups in postoperative bed rest time, length of hospitalization, or complication rates (P > 0.05). The postoperative Oswestry disability index and VAS were clearly improved in both groups compared with those of preoperation (P < 0.01). These two procedures have the same clinical outcomes (P > 0.05). CONCLUSIONS: Both the full endoscopy technique and intermittent endoscopy technique achieved good outcomes, whereas the intermittent endoscopy technique is a more effective option for a shorter duration surgery and lower hospitalization expenses.

Percutaneous Endoscopic Cervical Discectomy (PECD): An Analysis of Outcome, Causes of Reoperation.

OBJECTIVE: Percutaneous endoscopic cervical discectomy (PECD) is regarded as an effective treatment modality in cervical disc herniation, including radicular pain and lateral location of disc herniation. This study aimed to evaluate the clinical and radiologic outcomes of PECD along with the causes of reoperation and the technique itself. METHODS: Between January 2007 and November 2012, 101 patients underwent PECD at the Busan Wooridul Hospital. Three patients underwent a 2-level PECD. The mean follow-up period was 34 months (range, 18-72 months). The mean age was 46.1 years; the most common operation was at the C5-C6 level (n = 45), followed by C6-C7 (n = 35), C4-C5 (n = 16), and C3-C4 (n = 8). The clinical outcomes were evaluated via the visual analog scale of the neck and arm according to the Neck Disability Index and the modified Macnab criteria. Among 101 patients, 12 underwent an additional operation at the index level. Five patients had aggravated stenosis by disc height narrowing, 4 had recurred disc, 2 had remained disc, and 1 had sustained symptoms. RESULTS: After PECD, there was a significant improvement in the visual analog scale and Neck Disability Index scores (P < 0.001). According to the modified Macnab criteria, excellent concordance was achieved in 65 patients, good in 22, fair in 2, and poor in 12. The reoperation performed on 12 patients improved their clinical outcomes. The mean duration was 4.8 months (2 days to 18 months) until reoperation. There were 3 PECD revisions, 3 artificial disc replacements, 2 corpectomies, 2 anterior cervical discectomies and fusion with cages, and 2 transfers to another hospital. The common feature was older age (P = 0.016) and male sex (P = 0.031). Preoperative radiologic findings were characterized by the foraminal disc (P = 0.04), disc degeneration at the index level (P = 0.05), combined bony spur (P = 0.001), concomitant adjacent level degeneration (P = 0.019), cervical kyphosis (P = 0.015), and segmental angle deterioration after PECD (P = 0.038). No statistical correlation was seen between the operation level and herniation size (P > 0.05). CONCLUSIONS: In total, 87% patients showed successful clinical outcome. Poor and fair outcomes at initial PECD were overcome by revision surgery, which improved outcomes. Although PECD is a promising minimally invasive procedure for cervical disc treatment, the indications for PECD should be considered carefully.

Navigation improves the learning curve of transforamimal percutaneous endoscopic lumbar discectomy.

PURPOSE: Beginners usually need increased punctures and dozens of fluoroscopy in learning transforamimal percutaneous endoscopic lumbar discectomy (tPELD). Navigator-assisted spinal surgery (NASS) is a novel technique that could induce a definite trajectory. The retrospective study aimed to investigate the impact of a definite trajectory on the learning curve of tPELD. METHODS: A total of 120 patients with symptomatic lumbar disc herniation who received tPELD between 2012 and 2014. Patients receiving tPELD with NASS technique by one surgeon were regarded as group A, and those receiving conventional methods by another surgeon were regarded as group B. Each group was divided into three subgroups (case 1-20, case 21-40, case 41-60). RESULTS: The fluoroscopy times were 22.62 ± 3.80 in group A and 34.32 ± 4.78 in group B (P < 0.001). The pre-operative location time was 3.56 ± 0.60 minutes in group A and 5.49 ± 1.48 minutes in group B (P < 0.001). The puncture-channel time was 21.85 ± 4.31 minutes in group A and 34.20 ± 8.88 minutes in group B (P < 0.001). The operation time was 84.62 ± 9.20 minutes in group A and 101.97 ± 14.92 minutes in group B (P < 0.001), and the learning curve of tPELD in group A was steeper than that in group B. No significant differences were detected in patient-reported outcomes, hospital stay, patient satisfaction, and complication rate between the two groups (p > 0.05). CONCLUSIONS: Definite trajectory significantly reduced the operation time, preoperative location time, puncture-channel time, and fluoroscopy times of tPELD by beginners, and thus reshaped the learning curve of tPELD and minimized the radiation exposure.

A Strategy of Percutaneous Endoscopic Lumbar Discectomy for Migrated Disc Herniation.

OBJECTIVE: Percutaneous endoscopic lumbar discectomy (PELD) with remarkable advancements has led to successful results comparable with open discectomy; however, its application in herniated disc (HD) with migration is still challenging and technically demanding. The purpose of this study is to propose various strategies for PELD according to HD with migration. METHODS: A retrospective review was performed on 434 consecutive patients who had undergone PELD. HD with migration was classified into 4 zones: low-grade up/down and high-grade up/down based on the extent and direction of migration. Clinical outcomes were assessed by visual analogue scale score for back and leg pain, Oswestry Disability Index, and modified Macnab criteria. Endoscopic approaches and techniques were analyzed depending on HD with migration. RESULTS: A total of 149 patients underwent PELD for HD with migration. There were 93 low-grade down HD patients, 13 high-grade down, 11 low-grade up, and 32 high-grade up. High-grade up HDs were removed with the outside or outside-in techniques from L1-2 to L4-5. High-grade down HDs were removed via the outside technique with additional foraminoplasty. Low-grade up/down HDs with disc space continuity were removed with the inside-out technique. Meanwhile, at the L5-S1 level, interlaminar PELD was used to treat high-grade up/down HD with migration. The mean visual analogue scale score for back pain, leg pain, and Oswestry Disability Index were significantly improved after PELD. Favorable outcome was achieved in 90.6% of cases. CONCLUSIONS: An appropriate strategy for PELD is important for successful removal of HD considering the extent of migration and direction.

Relationship Between Percutaneous Procedures and Lumbar Infections Based on Data From The National Health Insurance Review & Assessment Service of Korea.

STUDY DESIGN: A study from the National health insurance database. OBJECTIVE: To investigate the relationship between percutaneous procedures or open surgeries and spinal infections using the 5-year large unit national dataset. SUMMARY OF BACKGROUND DATA: There is no nation-based research data on the relationship between percutaneous procedures and spinal infections in Korea. MATERIALS AND METHODS: This study used disease codes (ICD-10: International Classification of Disease) and operation fee codes (national medical insurance) registered in the National Health Insurance Review & Assessment Service for the 5 years from 2007 to 2011. Using the above disease codes, the number of each percutaneous procedure, open surgery, and the number of lumbar infections were investigated by the regional and national units, and the relationship between procedures or open surgeries and lumbar infection was compared statistically. RESULTS: Lumbar infection showed a gradual growing annual trend, with a 3-fold increase in 2011 compared with 2007. Percutaneous procedures (nerve blocks) increased by approximately 2.6 times over 4 years. Kyphoplasty tended to decrease each year. Open surgeries (posterior fusion, discectomy, and laminectomy) were at a similar level each year. Lumbar infection and percutaneous procedures were positively correlated, and a negative correlation was observed between kyphoplasty and open surgeries. The incidence of lumbar infection was higher in large cities than provinces and increased 2-3 times in 2011 compared with 2007 in all regions. CONCLUSIONS: There was no significant difference in the number of open surgeries for the 5-year study, but the number of percutaneous procedures (nerve blocks) increased each year, showing an approximate 4-fold increase in 4 years. Lumbar infection showed a positive correlation with percutaneous procedures, and kyphoplasty and open surgeries were negatively correlated. Therefore, as selective nerve block procedure is also considered an important factor affecting the growing trend of lumbar infections, unnecessary procedures should be avoided to reduce the absolute number of infections.

Long-term outcomes of patients with lumbar disc herniation treated with percutaneous discectomy: comparative study with microendoscopic discectomy.

We assessed the long-term outcomes of patients with lumbar disc herniation treated with percutaneous lumbar discectomy (PLD) or microendoscopic discectomy (MED). A retrospective study was performed in consecutive patients with lumbar disc herniation treated with PLD (n = 129) or MED (n = 101) in a single hospital from January 2000 to March 2002. All patients were followed up with MacNab criteria and self-evaluation questionnaires comprising the Oswestry Disability Index and Medical Outcomes Study 36-Item Short-Form Health Survey. Several statistical methods were used for analyses of the data, and a p value of <0.05 was considered to be statistically significant. A total of 104 patients (80.62%) with PLD and 82 patients (81.19%) with MED were eligible for analyses, with a mean follow-up period of 6.64 +/- 0.67 years and 6.42 +/- 0.51 years, respectively. There were no significant differences between the two groups in age, number of lesions, major symptoms and physical signs, and radiological findings. According to the MacNab criteria, 75.96% in the PLD group and 84.15% in the MED group achieved excellent or good results, respectively, this was statistically significant (p = 0.0402). With the Oswestry Disability Index questionnaires, the average scores and minimal disability, respectively, were 6.97 and 71.15% in the PLD group and 4.89 and 79.27% in the MED group. Total average scores of Medical Outcomes Study 36-Item Short-Form Health Survey were 75.88 vs. 81.86 in PLD group vs. MED group (p = 0.0582). The cost and length of hospitalization were higher or longer in MED group, a statistically significant difference (both p < 0.0001). Long-term complications were observed in two patients (2.44%) in the MED group, no such complications were observed in the PLD group. Both PLD and MED show an acceptable long-term efficacy for treatment of lumbar disc herniation. Compared with MED patients, long-term satisfaction is slightly lower in the PLD patients; complications, hospitalization duration, and costs in PLD group are also lower.

Systematic review of percutaneous lumbar mechanical disc decompression utilizing Dekompressor.

BACKGROUND: In recent years, a number of minimally invasive nuclear decompression techniques for lumbar disc prolapse, protrusion, and/or herniation have been introduced, including the Dekompressor a device utilizing an Archimedes screw. The primary goal of the surgical treatment of nerve root compression from a disc protrusion continues to be the relief of compression by removing the herniated nuclear material with open discectomy. However, poor results have been reported for contained disc herniations with open surgical interventions. The results with several alternative techniques including the Dekompressor, automated percutaneous discectomy, and laser discectomy have been described, but are not convincing. There is a paucity of evidence for all decompression techniques. STUDY DESIGN: A systematic review of the mechanical disc decompression with Dekompressor literature. OBJECTIVE: The objective of this systematic review is to evaluate the clinical effectiveness of the Dekompressor, a high rotation per minute device utilizing an Archimedes screw, used in mechanical lumbar disc decompression. METHODS: The literature search was conducted utilizing a comprehensive strategy for mechanical disc decompression utilizing the Dekompressor. A literature search was conducted using only English language literature in a comprehensive search of databases including PubMed, EMBASE, the Cochrane Library, along with systematic reviews, and cross-references from reviews, systematic reviews, and individual articles. The quality of the manuscripts included was evaluated according to Cochrane review criteria for randomized controlled trials (RCTs), and for observational studies with the criteria developed by the Agency for Healthcare Research and Quality (AHRQ). The level of evidence developed by the United States Preventive Services Task Force (USPSTF) was utilized in this review. The evidence was classified as Level I, II, or III with 3 subcategories in Level II for a total of 5 levels of evidence. OUTCOME MEASURES: Pain relief was the primary outcome measure. Other outcome measures were functional improvement, improvement of psychological status, opioid intake, and return to work. Short-term effectiveness was defined as one year or less, whereas, long-term effectiveness was defined as greater than one year. RESULTS: Based on USPSTF criteria the indicated level of evidence for the mechanical high RPM device or Dekompressor is Level III for short- and long-term relief. LIMITATIONS: Lack of literature, both randomized and observational. CONCLUSION: This systematic review illustrates Level III evidence for mechanical percutaneous disc decompression procedures with the high RPM device or Dekompressor.

Automated percutaneous lumbar discectomy for the contained herniated lumbar disc: a systematic assessment of evidence.

BACKGROUND: Lumbar disc prolapse, protrusion, and extrusion account for less than 5% of all low back problems, but are the most common causes of nerve root pain and surgical interventions. The typical rationale for traditional surgery is an effort to provide more rapid relief of pain and disability. It should be noted that the majority of patients will recover with conservative management. The primary rationale for any form of surgery for disc prolapse associated with radicular pain is to relieve nerve root irritation or compression due to herniated disc material. The primary modality of treatment continues to be either open or microdiscectomy, but several alternative techniques including automated percutaneous lumbar discectomy (APLD) have been described. However, there is a paucity of evidence for all decompression techniques, specifically alternative techniques including automated and laser discectomy. STUDY DESIGN: A systematic review of the literature. OBJECTIVE: To determine the effectiveness of APLD. METHODS: A comprehensive evaluation of the literature relating to automated lumbar disc decompression was performed. The literature was evaluated according to Cochrane review criteria for randomized controlled trials (RCTs), and Agency for Healthcare Research and Quality (AHRQ) criteria was utilized for observational studies. A literature search was conducted of English language literature through PubMed, EMBASE, the Cochrane library, systematic reviews, and cross references from reviews and systematic reviews. The level of evidence was classified as Level I, II, or III with 3 subcategories in Level II based on the quality of evidence developed by the United States Preventive Services Task Force (USPSTF). OUTCOME MEASURES: Pain relief was the primary outcome measure. Other outcome measures were functional improvement, improvement of psychological status, opioid intake, and return to work. Short-term effectiveness was defined as one year or less, whereas, long-term effectiveness was defined as greater than one year. RESULTS: Based on USPSTF criteria, the indicated evidence for APLD is Level II-2 for short- and long-term relief. LIMITATIONS: Paucity of RCTs in the literature. CONCLUSION: This systematic review indicated Level II-2 evidence for APLD. APLD may provide appropriate relief in properly selected patients with contained lumbar disc prolapse.

Comparison of a minimally invasive procedure versus standard microscopic discotomy: a prospective randomised controlled clinical trial.

A Prospective randomised controlled study was done to determine statistical difference between the standard microsurgical discotomy (MC) and a minimally invasive microscopic procedure for disc prolapse surgery by comparing operation duration and clinical outcome. Additionally, the transferability of the results was determined by a bicentric design. The microscopic assisted percutaneous nucleotomy (MAPN) has been advocated as a minimally invasive tubular technique. Proponents have claimed that minimally invasive procedures reduce postoperative pain and accelerate the recovery. In addition, there exist only a limited number of well-designed comparison studies comparing standard microdiscotomy to a tubular minimally invasive technique that support this claim. Furthermore, there are no well-designed studies looking at the transferability of those results and possible learning curve phenomena. We studied 100 patients, who were planned for disc prolapse surgery at two centres [50 patients at the developing centre (index) and 50 patients at the less experienced (transfer) centre]. The randomisation was done separately for each centre, employing a block-randomisation procedure with respect to age and preoperative Oswestry score. Operation duration was chosen as a primary outcome parameter as there was a distinguished shortening observed in a preliminary study at the index centre enabling a sound case number estimation. The following data were compared between the two groups and the centres with a 12-month follow-up: surgical times (operation duration and approach duration), the clinical results, leg and back pain by visual analogue scale, the Oswestry disability index, length of hospital stay, return to work time, and complications. The operation duration was statistically identical for MC (57.8 +/- 20.2 min) at the index centre and for MAPN (50.3 +/- 18.3 min) and MC (54.7 +/- 18.1 min) at the transfer centre. The operation duration was only significantly shorter for the MAPN technique at the index centre with 33.3 min (SD 12.1 min). There was a huge clinical improvement for all patients regardless of centre or method revealed by a repeated measures ANOVA for all follow-up visits Separate post hoc ANOVAs for each centre revealed that there was a significant time-method (MAPN vs. MC) interaction at the index centre (F = 3.75, P = 0.006), whereas this crucial interaction was not present at the transfer centre (F = 0.5, P = 0.7). These results suggest a slightly faster clinical recovery for the MAPN patients only at the index centre. This was due to a greater reduction in VAS score for back pain at discharge, 8-week and 6-month follow up (P < 0.002). The Oswestry-disability scores reached a significant improvement compared to the initial values extending over the complete follow-up at both centres for both methods without revealing any differences for the two methods in either centre. There was no difference regarding complications. The results demonstrate that a shorter operation duration and concomitant quicker recovery is comprehensible at an experienced minimally invasively operating centre. These advantages could not be found at the transfer centre within 25 minimally invasive procedures. In conclusion both procedures show equal mid term clinical results and the same complication rate even if the suggested advantages for the minimally invasive procedure could not be confirmed for the transfer centre within the framework of this study.

Percutaneous transforaminal lumbar interbody fusion for the treatment of degenerative lumbar instability.

OBJECTIVE: Percutaneous spinal instrumentation techniques may be helpful to reduce approach-related morbidity inherent to conventional open surgery. This article reports technique, clinical outcomes, and fusion rates of percutaneous transforaminal lumbar interbody fixation (pTLIF). Results are compared with those of mini-open transforaminal lumbar interbody fixation (oTLIF) using a muscle splitting (Wiltse) approach. METHODS: pTLIF was performed in 43 patients with single-level and 10 patients with bi- or multilevel lumbar discopathy or degenerative pseudolisthesis resulting in axial back pain and claudication, pseudoradicular, or radicular symptoms. Decompression, discectomy, and interbody cage insertion were performed through 18-mm tubular retractors followed by percutaneous pedicle screw-rod fixation. Clinical outcome was assessed by early postoperative pain scores (visual analog score) and standardized functional outcome questionnaires (American Academy of Orthopedic Surgeons lumbar spine and Roland-Morris low back pain score). Fusion rates were assessed by thin-slice computed tomographic scan at 16 months. Clinical outcome, time in the operating room, intraoperative blood loss, and postoperative access-site pain were compared with an institutional reference series of 67 oTLIF procedures. RESULTS: Excellent and good clinical results were obtained in 46 (87%) out of 53 patients at 16 months. The time spent in the operating room was equivalent and the blood loss reduced compared with oTLIF (P < 0.01). There was no morbidity related to instrumentation. Postoperative pain was significantly lower after pTLIF after the second postoperative day (P < 0.01). The overall clinical outcome was not different from oTLIF at 8 and 16 months. CONCLUSION: pTLIF allows for safe and efficient minimally invasive treatment of single and multilevel degenerative lumbar instability with good clinical results. Further prospective studies investigating long-term functional results are required to assess the definitive merits of percutaneous instrumentation of the lumbar spine.

Percutaneous nucleoplasty for discoradicular conflict.

Minimally invasive techniques for the treatment of degenerative pathology of the spine have come to be preferred by surgeons since the destructive effect on bony structures is eliminated and scar formation is dramatically reduced. A critical review of the pathogenetic mechanisms for low back pain and sciatalgia has recently yielded that mechanical compression is one but non essential component of the matter. The importance of chemical irritative processes is stressed. Coblation nucleoplasty is one of these minimally invasive techniques. It provokes ablation of the nucleus of the disk by a controlled thermal effect produced by radiofrequency. By this procedure one to two ml of tissue are colliquated in a few minutes. From February 2001 to May 2003 we treated 1390 patients for of lumbosciatalgic pain caused by disc pathology. The alteration consisted of disc bulging or contained disc herniation. Exclusion criteria as provided by the protocol of the multicentric study conceived by Conor O'Neill have been respected. This technique has been conceived in order to obtain progressive results in cases of contained disc herniation which has scanty natural tendency to shrinkage, as demonstrated by several studies on the natural history of evolution of this pathology. Contained disc herniation is a pathology most difficult to manage by conservative procedures, physiotherapy and drugs, but we all agree that open surgery should be avoided. By this minimally invasive procedure the patient will not be compelled to abandon physiotherapy and his normal daily activities for more than a few days.

The surgical treatment of the lumbar disc prolapse: nucleotomy with additional transpedicular dynamic stabilization versus nucleotomy alone.

STUDY DESIGN: Clinical and radiologic study evaluating the outcome after nucleotomy with dynamic stabilization compared with nucleotomy alone. OBJECTIVES: To investigate the effect of dynamic stabilization on the progression of segmental degeneration after nucleotomy. SUMMARY OF BACKGROUND DATA: Nucleotomy as treatment for lumbar disc prolapse in combination with initial segment degeneration may lead to segmental instability. Dynamic stabilization systems restrict segmental motion and thus prevent further degeneration of the lumbar spine. They are designed to avoid the disadvantages of rigid fixation, such as pseudarthrosis and adjacent segment degeneration. METHODS: Eighty-four patients underwent nucleotomy of the lumbar spine for the treatment of symptomatic disc prolapse. Additional dynamic stabilization (DYNESYS) was performed in 35 of those cases. All patients showed signs of initial disc degeneration (MODIC I). They underwent evaluation before surgery, 3 months after surgery, and at follow-up. The mean duration of follow-up was 34 months. Examinations included radiographs, magnetic resonance imaging (MRI), physical examination, and subjective patient evaluation using Oswestry score and visual analog scale (VAS). RESULTS: Clinical symptoms, Oswestry score, and VAS improved significantly in both groups after 3 months. At follow-up, a significant increase in the Oswestry score and in the VAS was seen only in the nonstabilized group. In the dynamically stabilized group, no progression of disc degeneration was noted at follow-up, whereas radiologic signs of accelerated segmental degeneration existed in the solely nucleotomized group. There were no implant-associated complications. CONCLUSIONS: The applied dynamic stabilization system is useful to prevent progression of initial degenerative disc disease of lumbar spinal segments after nucleotomy.