Percutaneous Transforaminal Endoscopic Discectomy Versus Open Microdiscectomy for Lumbar Disc Herniation: A Systematic Review and Meta-analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: To give a systematic overview of effectiveness of percutaneous transforaminal endoscopic discectomy (PTED) compared with open microdiscectomy (OM) in the treatment of lumbar disk herniation (LDH). SUMMARY OF BACKGROUND DATA: The current standard procedure for the treatment of sciatica caused by LDH, is OM. PTED is an alternative surgical technique which is thought to be less invasive. It is unclear if PTED has comparable outcomes compared with OM. METHODS: Multiple online databases were systematically searched up to April 2020 for randomized controlled trials and prospective studies comparing PTED with OM for LDH. Primary outcomes were leg pain and functional status. Pooled effect estimates were calculated for the primary outcomes only and presented as standard mean differences (SMD) with their 95% confidence intervals (CI) at short (1-day postoperative), intermediate (3-6 months), and long-term (12 months). RESULTS: We identified 2276 citations, of which eventually 14 studies were included. There was substantial heterogeneity in effects on leg pain at short term. There is moderate quality evidence suggesting no difference in leg pain at intermediate (SMD 0.05, 95% CI -0.10-0.21) and long-term follow-up (SMD 0.11, 95% CI -0.30-0.53). Only one study measured functional status at short-term and reported no differences. There is moderate quality evidence suggesting no difference in functional status at intermediate (SMD -0.09, 95% CI -0.24-0.07) and long-term (SMD -0.11, 95% CI -0.45-0.24). CONCLUSION: There is moderate quality evidence suggesting no difference in leg pain or functional status at intermediate and long-term follow-up between PTED and OM in the treatment of LDH. High quality, robust studies reporting on clinical outcomes and cost-effectiveness on the long term are lacking.Level of Evidence: 2.

A Cost-utility Analysis of Percutaneous Endoscopic Lumbar Discectomy for L5-S1 Lumbar Disc Herniation: Transforaminal versus Interlaminar.

STUDY DESIGN: A cost-utility analysis (CUA). OBJECTIVE: The aim of this study was to evaluate the cost-effectiveness of percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID) techniques for the treatment of L5-S1 lumbar disc herniation (LDH). SUMMARY OF BACKGROUND DATA: The annual cost of treatment for lumbar disc herniation is staggering. As the two major approaches of percutaneous endoscopic lumbar discectomy (PELD): percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID) have gained recognition for the treatment of L5-S1 lumbar disc herniation (LDH) and showed similar clinical outcome. ost-utility analysis (CUA) can help clinicians make appropriate decisions about optimal health care for L5-S1 LDH. METHODS: Fifty and 25 patients were included in the PETD and PEID groups of the study. Patients' basic characteristics, health care costs, and clinical outcome of PETD and PEID group were collected and analyzed. Quality-adjusted life-years (QALYs) were calculated and validated by EuroQol five-dimensional (EQ-5D) questionnaire. Cost-effectiveness was determined by the incremental cost per QALY gained. RESULTS: The mean total cost of the PETD group was $5275.58 ±â€Š292.98 and the PEID group was $5494.45 ±â€Š749.24. No significant differences were observed in hospitalization expenses, laboratory and radiographic evaluations expenses, surgical expenses, and drug costs. Surgical equipment and materials costs, and anesthesia expense in the PEID group were significantly higher than in the PETD group (P < 0.001). Clinical outcomes, including Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) scores, and Japanese Orthopaedic Association (JOA), also showed no significant differences between the two groups. The cost-effectiveness ratio of PETD and PEID were $6816.05 ±â€Š717.90/QALY and $7073.30 ±â€Š1081.44/QALY, respectively. The incremental cost-effectiveness ratios (ICERs) of PEID over PETD was $21887.00/QALY. CONCLUSION: Observed costs per QALY gained for L5-S1 LDH with PETD or PEID were similar for patients, demonstrating that the two different approaches of PELD are equally cost-effective and valuable interventions. LEVEL OF EVIDENCE: 5.

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.

Comparison of Three Minimally Invasive Spine Surgery Methods for Revision Surgery for Recurrent Herniation After Percutaneous Endoscopic Lumbar Discectomy.

BACKGROUND: Patients who experience a recurrence of percutaneous endoscopic lumbar discectomy (PELD) need to undergo revision surgery when they fail to respond to conservative therapy. Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), microendoscopic discectomy (MED), and PELD are 3 common minimally invasive surgical approaches for PELD recurrence. However, there have been no studies that have focused on the selection of the minimally invasive surgical method for PELD recurrence. METHODS: Seventy-four patients who underwent revision surgery (MIS-TLIF, 26 cases; MED, 20 cases; PELD, 28 cases) for PELD recurrence were enrolled in this study. The preoperative characteristics and perioperative data were collected. Additionally, the clinical outcomes (visual analogue scale, Oswestry Disability Index, and the 12-item Short Form Health Survey) were collected and assessed at 1, 3, 6, 9, and 12 months postoperatively. RESULTS: No significant differences in clinical outcomes over time were observed between these 3 surgical approaches. MED and PELD were associated with greater pain-relief effects at 1 month after surgery than MIS-TLIF, but this effect equalized at 3 months postoperatively. MED and PELD exhibited the advantages of reductions in operation time, blood loss, hospital stay and total cost compared to MIS-TLIF. However, MED and PELD also were significantly associated with greater recurrence rates than MIS-TLIF. CONCLUSIONS: None of the three surgical approaches exhibited clear advantages in long-term pain or functional scores. MED and PELD were associated with lower costs and better perioperative effects than MIS-TLIF. However, compared with MIS-TLIF, the higher recurrence rates of MED and PELD should not be ignored.

Effectiveness of percutaneous laser disc decompression versus conventional open discectomy in the treatment of lumbar disc herniation; design of a prospective randomized controlled trial.

BACKGROUND: The usual surgical treatment of refractory sciatica caused by lumbar disc herniation, is open discectomy. Minimally invasive procedures, including percutaneous therapies under local anesthesia, are increasingly gaining attention. One of these treatments is Percutaneous Laser Disc Decompression (PLDD). This treatment can be carried out in an outpatient setting and swift recovery and return to daily routine are suggested. Thus far, no randomized trial into cost-effectiveness of PLDD versus standard surgical procedure has been performed. We present the design of a randomized controlled trial, studying the cost-effectiveness of PLDD versus conventional open discectomy in patients with sciatica from lumbar disc herniation. METHODS/DESIGN: The study is a randomized prospective multi-center trial, in which two treatment strategies are compared in a parallel group design. Patients (age 18-70 years) visiting the neurosurgery department of the participating hospitals, are considered for inclusion in the trial when sciatica due to lumbar disc herniation has lasted more than 8 weeks. Patients with disc herniation smaller than 1/3 of the spinal canal diameter, without concomitant lateral recess stenosis or sequestration, are eligible for participation, and are randomized into one of two treatment arms; either Percutaneous Laser Disc Decompression or conventional discectomy. The functional outcome of the patient, as assessed by the Roland Disability Questionnaire for Sciatica at 8 weeks and 1 year after treatment, is the primary outcome measure. The secondary outcome parameters are recovery as perceived by the patient, leg and back pain, incidence of re-intervention, complications, quality of life, medical consumption, absence of work and secondary costs. DISCUSSION: Open discectomy is still considered to be the golden standard in the surgical treatment of lumbar disc herniation. Whether Percutaneous Laser Disc Decompression has at least as much efficacy as the standard surgical procedure, and is more cost-effective, will be determined by this trial.

Laminectomy compared with laparoscopic diskectomy and outpatient laparoscopic diskectomy for herniated L5-S1 intervertebral disks.

The objective of this study was to evaluate the clinical efficacy and cost effectiveness of inpatient and outpatient laparoscopic lumbar diskectomy (LLD) compared with laminectomy (LAM) in the surgical treatment of disabling L5-S1 disk herniation. Sixty-two adults underwent surgery for herniated L5-S1 intervertebral disks (31 LLD and 31 LAM). Operative blood loss (EBL) (milliliters), operative time (ORT) (minutes), hospital stay (LOS), and rehabilitation time to normal activity (REHAB) (days), recurrent symptoms, postoperative morbidity, percent pain free, and hospital patient charges were calculated. Thirty LLD patients (97%) had immediate relief of disk pain. Morbidity after LLD included transient urinary retention (one) and rectus hematoma (one). One LAM patient had a pseudomeningocele. Among patients observed for > or =6 months, with a median follow up time of 34 months, 22 of 25 LLD patients (88%) returned to normal activity, while 12 of the LAM group (52%) were disabled (p = 0.004). Functional outcome was improved by LLD for workers compensation patients followed > or =6 months, with 86% LAM disabled, vs. 10% LLD (p = 0.001). Sixteen LLD patients (52%) and 18 (58%) of the LAM group needed postoperative physical therapy. Four LLD patients recurred; three required reoperation. Four LAM patients had surgery for recurrent disk herniation. ORT was longer for LLD than LAM (210 vs. 158 minutes, median, p < 0.05). EBL and REHAB time were significantly reduced with LLD, vs. LAM. With a median follow-up of 34 months, 58% of LLD and 39% of LAM patients followed > or =6 months were pain free. Outpatient LLD (n = 9) reduced LOS (1 day vs. 2 days and 4 days, p < 0.01) and lowered patient charges ($4,405 vs. $5,723 and $7,192, p < 0.01) compared with inpatient LLD (n = 23) and LAM, respectively. LLD is a safe, cost-effective, minimally invasive alternative to LAM for treating herniated L5-S1 disks. Compared with LAM, LLD reduces EBL, LOS, REHAB time, and patient charges, improves function, and increases long-term pain relief. Cost effectiveness is optimized when LLD is performed as outpatient surgery.

Social insurance cost of standard discectomy and percutaneous nucleotomy. A retrospective study of 87 social insurance claim files of male blue collar workers.

A retrospective review of social insurance claim files of male blue collar workers was conducted to compare the social insurance costs of percutaneous lumbar nucleotomy with standard lumbar discectomy ; 29 percutaneous nucleotomy procedures were matched with 58 standard discectomies all carried out between January 1992 and December 1994. It was concluded that a standard discectomy procedure results in significantly higher costs during hospitalisation with respect to surgery, anaesthesia and hospital stay. A percutaneous nucleotomy leads to a significantly higher outpatient expenditure especially in radiology and medical devices. The relative proportion of outpatient practitioner's visits and hospital stay costs was significantly higher for the standard discectomy whereas medical devices had a relatively higher share in outpatient expenditure for the percutaneous nucleotomy. In this population of 87 compensation claimants, the average social insurance costs did not significantly differ between the percutaneous nucleotomy and the standard discectomy.

Efficacy of lumbar discectomy and percutaneous treatments for lumbar disc herniation.

The changing health care environment necessitates careful re-evaluation of all costly elective procedures. Low back surgery is a typical example. This article reviews the current literature addressing the efficacy of surgery and invasive percutaneous treatments for discogenic sciatica. It also discusses the prospects for the continuation of reimbursement for these procedures under a system of managed health care. Relevant articles were identified using the MEDLINE and Current Contents databases, from bibliographies of articles identified from these databases, from recommendations of experts in the field, and from the Canadian Cochrane++ Collaboration. The review includes randomized clinical trials, meta-analyses, published practice guidelines and large case series. The literature is classified and discussed in these quality strata. The review includes 9 randomized trials, 6 meta-analyses or review articles, one evidence-based practice guideline, 38 surgical case series and 35 additional references. Though incomplete, the existing evidence indicates that open discectomy shortens the duration of discogenic sciatica in selected patients. Neurologic outcomes are similar in operated and unoperated patients. Predominant leg pain, evidence of nerve root tension and concordant symptoms and imaging findings, are associated with favorable surgical results. Chemonucleolysis is also associated with more rapid pain relief than conservative treatment, but provides less certain benefit than standard discectomy. Available data on other percutaneous disc treatments do not currently support a statement on efficacy. Various percutaneous techniques are available but there is no solid scientific evidence of efficacy. The benefits of open discectomy, principally reduced duration of pain, appear to justify its use in carefully selected patients when discogenic sciatica fails to improve with conservative measures. Though elective, the procedure will probably continue to be available under managed care, but with increasing scrutiny of operative indications.

Functional results of percutaneous laser discectomy.

The purpose of the study was to evaluate laser disc decompression with the KTP 532 laser, used in conjunction with a percutaneous technique, in contained, small to moderately sized lumbar disc herniation. Sixty-three patients who had a contained herniated nucleus pulposus (HNP) and underwent percutaneous laser disc decompression were prospectively studied. Sixty-one were available for follow-up. Access to the disc space was attained with an 18-gauge probe, followed by dilating cannulas guided with an image intensifier. Discography was not performed. The power was set at 10 W, and laser pulses were delivered for 0.2 seconds, with an interval of 0.5 seconds. A total of 1250 J was delivered to the disc space. The average follow-up was 31.75 months (range, 20 to 45 months). Overall, 44 patients (72%) achieved relief of radicular pain, and 33 patients (54%) achieved relief of low back pain. Thirty-six of 61 patients (59%) returned to work by postoperative week 4. Fourteen patients failed treatment, experiencing persistent symptoms (with scores on the Andrews and Lavyne rating scale of < or = 3). In this study group, optimal results were obtained when symptoms were treated within 1 year of presentation. Results from a historical control group are provided for comparison.

An economic evaluation of a clinical trial to compare automated percutaneous lumbar discectomy with microdiscectomy in the treatment of contained lumbar disc herniation.

STUDY DESIGN: A cost-effectiveness study of automated percutaneous lumbar discectomy (APLD) vs. microdiscectomy in the treatment of contained lumbar herniation in a randomized controlled trial. OBJECTIVES: To quantify hospital costs and other public sector expenditure; to collect socioeconomic data that might bear on the recovery rate of patients and their private costs; and to relate costs to clinical outcomes. SUMMARY OF BACKGROUND DATA: The authors are aware of no similar economic evaluation in this field. METHODS: The surgical procedures were costed from detailed lists of the time spent and resources used. Socioeconomic patient data were collected by questionnaires administered around the time of the operation and on follow-up at 6 months. Statistical analysis was by the chi-square method. RESULTS: There was no evidence that either procedure imposed significantly greater costs on patients or nonhospital medical services. CONCLUSION: It was demonstrated that, within the restrictions imposed by the data set, automated percutaneous lumbar discectomy was less cost-effective than microdiscectomy.

Percutaneous laser disc nucleotomy.

In September 1988, the first laser decompression of a symptomatic contained bulging disc was performed in the United States. This author participated in a case study of 333 patients treated with the neodymium (Nd)-impregnated yttrium aluminum garnet (YAG) laser of 1064-nm wavelength. He also treated 117 patients with the potassium titanyl phosphate (KTP) laser of 532-nm wavelength. Detailed surgical techniques and followup statistics of the 117 patients treated with the KTP laser are presented and compared with those of a subset of 36 of the 333 patients treated with the Nd:YAG laser. Of the 117 patients treated with the KTP laser, 23 patients were at the 2-year followup, and 46 patients at the 1-year followup, at the time of this writing. A statistically significant reduction in overall average patient pain was documented by disc level as a function of followup duration. Variation in average specific neurologic findings (knee jerk, reflex, toe strength, ankle jerk, pinprick, and Lasague's sign) by disc level as a function of followup duration was not significant. These procedures were accomplished with no major complications. The success rate based on a 2-year followup was 72%. The success rate with the Nd:YAG laser was very similar, at 70%. These data provide encouraging information substantiating the validity of laser surgery for percutaneous disc nucleotomy.