Unilateral biportal endoscopy via two different approaches for upper lumbar disc herniation: a technical note.

BACKGROUND: The traditional surgical procedures for upper lumbar disc herniation (ULDH) usually lead to frequent complications. We aim to investigate the clinical efficacy of the unilateral biportal endoscopy (UBE) technique in treating upper lumbar disc herniation (ULDH). METHODS: From January 2020 to December 2021, the clinical data of 28 patients with ULDH treated with the UBE technique were collected and analyzed for surgery time under UBE, postsurgical drainage, postsurgical hospital stay, and complications. The clinical efficacy was evaluated according to the modified MacNab score, Oswestry disability index (ODI), and visual analogue scale (VAS) of low back pain and lower limb pain before the surgery; one week, one month, and three months after the surgery; and at the last follow-up. RESULTS: All patients underwent the UBE surgery successfully. The surgery time under UBE for non-fusion cases was 47.50 ± 11.84 min (monosegment) and 75.00 ± 20.66 min (two segments), while that for fusion cases was 77.50 ± 21.02 min. The postsurgical drainage for non-fusion cases was 25.00 ± 13.94 mL (monosegment) and 38.00 ± 11.83 mL (two segments), while that for fusion cases was 71.25 ± 31.72 mL. The postsurgical hospital stay was 8.28 ± 4.22 days. The follow-up time was 15.82 ± 4.54 months. The VAS score for each time period after the surgery was significantly lower (P < 0.05), while the ODI was significantly higher than that before the surgery (P < 0.05). According to the modified MacNab scoring standard, the ratio of excellent to good was 96.43% at the last follow-up. Two patients experienced transient numbness and pain in their lower limbs and no activity disorder after the surgery, and they recovered after conservative treatment. CONCLUSIONS: The clinical effect of UBE technique in treating ULDH was reliable. According to the needs of the disease, the interlaminar approach or paraspinal approach of the UBE technique was selected. This technique took into account the effect of treatment, achieved the purpose of minimal invasiveness, and did not require special instruments. Therefore, it has the potential for clinical application.

Cauda equina syndrome with surgical intervention in pregnancy during the periviable period.

INTRODUCTION: Cauda equina syndrome (CES) following lumbar disc herniation is exceedingly rare in pregnancy and there is limited literature outlining management of CES in pregnancy. There is further limited data addressing the management of periviable pregnancies complicated by CES. CASE PRESENTATION: A 38-year-old female at 22 weeks gestation presented with worsening lower back pain radiating to the right posterior lower extremity. She was initially managed with conservative therapy, but re-presented with worsening neurologic symptoms, including fasciculations and perineal numbness. Magnetic resonance imaging showed a large herniated disc at L4-5, and given concern for CES, she underwent emergent decompression surgery, which was complicated by a superficial wound dehiscence. She ultimately carried her pregnancy to term and had a cesarean delivery. The patient's residual neurologic symptoms continued to improve with physical therapy throughout the postpartum period. DISCUSSION: Cauda equina syndrome is a rare spinal condition with potentially devastating outcomes if not managed promptly. Diagnosis and management of CES in pregnancy is the same as in non-pregnant patients, however, standardization of patient positioning for surgery, surgical approach, anesthetic use, and fetal considerations is lacking. A multidisciplinary approach is critical, especially at periviable gestational ages of pregnancy. Our case and review of the literature demonstrates that patients in the second trimester can be managed surgically with prone positioning, intermittent fetal monitoring, and continued management of the pregnancy remains unchanged. Given the rarity of these cases, there is a need for a consensus on management and continued care in pregnant patients with CES.

Comparison of the Outcomes of Anterior Cervical Discectomy and Fusion and Cervical Disc Replacement for Cervical Disc Disease.

OBJECTIVE: To compare the radiological outcome and development of heterotopic ossification (HO) following single-segment anterior cervical discectomy and fusion (ACDF) and cervical disc replacement (CDR) for cervical disc herniation and evaluate their impact on surgical success. STUDY DESIGN: Descriptive comparative study. Place and Duration of the Study: Neurosurgery Department at Bozyaka Education and Research Hospital, Izmir, Turkiye, between January 2020 and June 2022. METHODOLOGY: Patients aged 18-70 years with radicular neck pain unresponsive to conventional medical treatment and an MRI-confirmed diagnosis were included. Patients with osteoporosis (OP) were excluded. Patients were randomised into two treatment groups (ACDF and CDR) and stratified by age and symptom severity. Radiographic assessments and HO classification according to McAfee were performed. RESULTS: Among the included patients, 56 underwent ACDF and 45 underwent CDR. The mean patient age was 48.29 ± 9.530 and 41.84 ± 7.239 years in the ACDF and CDR groups, respectively (p <0.001). The postoperative disc height increased in both groups. The T1 slope was significantly higher preoperatively and in the early postoperative period in the CDR group than in the ACDF group (p = 0.001). HO was graded as 1, 2, 3, and 4 in 28 (27.7%), 6 (5.9%), 7 (6.9%), and 4 (3%) patients, respectively. CONCLUSION: ACDF and CDR provided similar improvements in radiological measurements and pain relief. Although both procedures significantly enhanced the patient's quality of life and disability scores, HO was more prevalent following CDR during long-term follow-up. KEY WORDS: Cervical disc replacement, Anterior cervical discectomy and fusion, Spinal surgery techniques, Heterotopic ossification.

A novel repair strategy using knotless squeeze anchors for lumbar disc herniation with endplate junction lesions under biportal endoscopic spinal surgery.

BACKGROUND: Annulus fibrosus-endplate (AF-EP) junction lesions are important determinants for lumbar disc herniation (LDH). Utilizing biportal endoscopic spinal surgery (BESS), we introduce a novel repair method using bioabsorbable PushLock anchors with suture fibers to stretch disconnected AF tissues to the vertebral cortex. METHODS: The viewing and working portals are established to excise herniated disc materials causing radiculopathy. Through the working portal, a suture strand is passed through the intact AF tissue near the lesion and retrieved using the Suture Crossing Device. Then, the knotless suture limbs are secured into the cortical bone socket of the vertebral body with a PushLock anchor. CONCLUSION: The procedure is a simple, safe, and feasible knotless suturing technique for the treatment of LDH with AF-EP junction lesions.

Basivertebral nerve ablation with concurrent lumbar laminotomy.

Lumbar radiculopathy due to impingement of nerve roots from facet hypertrophy and/or disc herniation can often coincide with vertebrogenic low back pain. This is demonstrated on MRI with foraminal stenosis and Modic changes. We examine the potential of using a combination of basivertebral nerve ablation (BVNA) and lumbar laminotomy as an alternative to traditional spinal fusion in specific patient populations. This unique combination of surgical techniques has not been previously reported in the medical literature. We report a man in his late 30s with chronic low back pain and lumbar radiculopathy, treated with BVNA and concurrent laminotomy. The patient reported progressive improvements in his mobility and pain over the next 2 years. We discuss the advantages of using this technique for lumbar radiculopathy and Modic changes compared with conventional surgical modalities.

Clinical effect of full endoscopic lumbar annulus fibrosus suture.

PURPOSE: The aim of this study was to investigate the clinical efficacy of full endoscopic lumbar annulus fibrosus suture in the treatment of single-segment lumbar disc herniation (LDH). METHODS: The clinical data of patients with single-segment LDH who underwent full endoscopic lumbar discectomy from January 2017 to January 2019 in our hospital were retrospectively analysed. Patients with full endoscopic lumbar discectomy combined with annulus fibrosus suture were divided into group A, and those with simple full endoscopic lumbar discectomy were divided into group B. The general information, surgery-related data, visual analog scale (VAS), Oswestry disability index (ODI), modified MacNab score at the last follow-up, reoperation rate and recurrence were compared between the two groups. RESULTS: All patients were followed up for 12 to 24 months, and the surgical time was 133.6 ± 9.6 min in group A and 129.0 ± 11.7 min in group B. The difference was not statistically significant (p > 0.05). The blood loss of group A was higher than that of group B, and the difference was statistically significant when comparing the groups (p < 0.05). The postoperative symptoms of patients in both groups were significantly relieved, and the VAS score of low back pain and ODI index were significantly lower than the preoperative ones at all postoperative time points (1 month after surgery, 3 months after surgery, and at the last follow-up) (p < 0.05), but there was no significant difference between the groups (p > 0.05). The excellent rate of MacNab at the last follow-up in the two groups were 93.55% and 87.80%, respectively, with no statistically significant difference (p > 0.05). At the last follow-up, the recurrence rate of group A was significantly lower than that of group B, and the difference was statistically significant (p < 0.05), while the difference between the reoperation rate of the two groups was not statistically significant (p > 0.05). CONCLUSIONS: Full endoscopic lumbar discectomy combined with annulus fibrosus repair reduces the postoperative recurrence rate and achieves satisfactory clinical outcomes.

Investigating the impact of cartilaginous endplate herniation on recovery from percutaneous endoscopic lumbar discectomy.

OBJECTIVE: This study aimed to evaluate the influence of herniation of cartilaginous endplates on postoperative pain and functional recovery in patients undergoing percutaneous endoscopic lumbar discectomy (PELD) for lumbar disc herniation (LDH). METHODS: A retrospective analysis was conducted on 126 patients with LDH treated with PELD at the Third Hospital of Hebei Medical University from January 2021 to January 2022. Whether cartilaginous endplates had herniated was identified by analyzing these specific findings from MRI scans: posterior marginal nodes, posterior osteophytes, mid endplate irregularities, heterogeneous low signal intensity of extruded material, and Modic changes in posterior corners and mid endplates. Patients were assessed for postoperative pain using the Visual Analogue Scale (VAS) and functional recovery using the Oswestry Disability Index (ODI) and Modified MacNab criteria. Statistical analyses compared outcomes based on the presence of herniation of cartilaginous endplates. RESULTS: Patients with herniation of cartilaginous endplates experienced higher pain scores early postoperatively but showed significant improvement in pain and functional status over the long term. The back pain VAS scores showed significant differences between the groups with and without herniation of cartilaginous endplates on postoperative day 1 and 1 month (P < 0.05). Leg pain VAS scores showed significant differences on postoperative day 1 (P < 0.05). Modic changes were significantly associated with variations in postoperative recovery, highlighting their importance in predicting patient outcomes. In patients with herniation of cartilaginous endplates, there were statistically significant differences in the back pain VAS scores at 1 month postoperatively and the ODI functional scores on postoperative day 1 between the groups with and without Modic changes (P < 0.05). There were no significant differences in the surgical outcomes between patients with and without these conditions regarding the Modified MacNab criteria (P > 0.05). CONCLUSION: Herniation of cartilaginous endplates significantly affect early postoperative pain and functional recovery in LDH patients undergoing PELD. These findings emphasize the need for clinical consideration of these imaging features in the preoperative planning and postoperative management to enhance patient outcomes and satisfaction.

Transforaminal endoscopic lumbar discectomy with two-segment foraminoplasty for the treatment of very highly migrated lumbar disc herniation: a retrospective analysis.

BACKGROUND: The surgical resection of very highly migrated lumbar disc herniation (VHM-LDH) is technically challenging owing to the absence of technical guidelines. Hence, in the present study, we introduced the transforaminal endoscopic lumbar discectomy (TELD) with two-segment foraminoplasty to manage VHM-LDH and evaluated its radiographic and midterm clinical outcomes. MATERIALS AND METHODS: The present study is a retrospective analysis of 33 consecutive patients with VHM-LDH who underwent TELD with two-segment foraminoplasty. The foraminoplasty was performed on two adjacent vertebrae on the basis of the migration direction of disc fragments to fully expose the disc fragments and completely decompress the impinged nerve root. The operation duration, blood loss, intra- and postoperative complications, and recurrences were recorded. Additionally, imageological observations were evaluated immediately after the procedure via magnetic resonance image and computerized tomography. Clinical outcomes were evaluated by calculating the visual analog scale (VAS) score and Oswestry Disability Index (ODI). The MacNab criterion was reviewed to assess the patients' opinions on treatment satisfaction. The resection rate of bony structures were quantitatively evaluated on postoperative image. The segmental stability was radiologically evaluated at least a year after the surgery. Additionally, surgery-related and postoperative complications were evaluated. RESULTS: The average age of the patients was 56.87 ± 7.77 years, with a mean follow-up of 20.95 ± 2.09 months. The pain was relieved in all patients immediately after the surgery. The VAS score and ODI decreased significantly at each postoperative follow-up compared with those observed before the surgery (P < 0.05). The mean operation duration, blood loss, and hospital stay were 56.17 ± 16.21 min, 10.57 ± 6.92 mL, and 3.12 ± 1.23 days, respectively. No residual disc fragments, iatrogenic pedicle fractures, and segmental instability were observed in the postoperative images. For both up- and down- migrated herniation in the upper lumbar region, the upper limit value of resection percentage for the cranial SAP, caudal SAP, and pedicle was 33%, 30%, and 34%, respectively; while those in the lower lumbar region was 42%, 36%, and 46%, respectively. At the last follow-up, the satisfaction rate of the patients regarding the surgery was 97%. Surgery-related complications including dural tear, nerve root injury, epidural hematoma, iatrogenic pedicle fractures, and segmental instability were not observed. One patient (3%) suffered from the recurrence of LDH 10 months after the initial surgery and underwent revision surgery. CONCLUSIONS: The TELD with two-segment foraminoplasty is safe and effective for VHM-LDH management. Proper patient selection and efficient endoscopic skills are required for applying this technique to obtain satisfactory outcomes.

Comparative outcomes of obese and non-obese patients with lumbar disc herniation receiving full endoscopic transforaminal discectomy: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to assess the impact of full endoscopic transforaminal discectomy (FETD) on clinical outcomes and complications in both obese and non-obese patients presenting with lumbar disc herniation (LDH). METHODS: A systematic search of relevant literature was conducted across various primary databases until November 18, 2023. Operative time and hospitalization were evaluated. Clinical outcomes included preoperative and postoperative assessments of the Oswestry Disability Index (ODI) and visual analogue scale (VAS) scores, conducted to delineate improvements at 3 months postoperatively and during the final follow-up, respectively. Complications were also documented. RESULTS: Four retrospective studies meeting inclusion criteria provided a collective cohort of 258 patients. Obese patients undergoing FETD experienced significantly longer operative times compared to non-obese counterparts (P = 0.0003). Conversely, no statistically significant differences (P > 0.05) were observed in hospitalization duration, improvement of VAS for back and leg pain scores at 3 months postoperatively and final follow-up, improvement of ODI at 3 months postoperatively and final follow-up. Furthermore, the overall rate of postoperative complications was higher in the obese group (P = 0.02). The obese group demonstrated a total incidence of complications of 17.17%, notably higher than the lower rate of 9.43% observed in the non-obese group. CONCLUSION: The utilization of FETD for managing LDH in individuals with obesity is associated with prolonged operative times and a higher total complication rate compared to their non-obese counterparts. Nevertheless, it remains a safe and effective surgical intervention for treating herniated lumbar discs in the context of obesity.

Lumbar percutaneous transforaminal endoscopic discectomy: a retrospective survey on the first 172 adult patients treated in Denmark.

PURPOSE: To evaluate patient demographics, surgery characteristics, and patient-reported clinical outcomes related to the implementation of lumbar PTED in Denmark by surgeons novice to the PTED technique. METHODS: All adult patients treated with a lumbar PTED from our first surgery in October 2020 to December 2021 were included. Data was generated by journal audit and telephone interview. RESULTS: A total of 172 adult patients underwent lumbar PTED. Surgery duration was a median of 45.0 (35.0-60.0) minutes and patients were discharged a median of 0 (0-1.0) days after. Per operatively one procedure was converted to open microdiscectomy due to profuse bleeding. Post operatively one patient complained of persistent headache (suggestive of a dural tear), two patients developed new L5 paresthesia, and three patients had a newly developed dorsal flexion paresis (suggestive of a root lesion). Sixteen patients did not complete follow-up and 24 (14.0%) underwent reoperation of which 54.2% were due to residual disk material. Among the remaining 132 patients, lower back and leg pain decreased from 7.0 (5.0-8.5) to 2.5 (1.0-4.5) and from 8.0 (6.0-9.1) to 2.0 (0-3.6) at follow-up, respectively (p < 0.001). Additionally, 93.4% returned to work and 78.8% used less analgesics. Post hoc analysis comparing the early half of cases with the latter half did not find any significant change in surgery time, complication and reoperation rates, nor in pain relief, return to work, or analgesia use. CONCLUSION: Clinical improvements after lumbar PTED performed by surgeons novel to the technique are satisfactory, although the reoperation rate is high, severe complications may occur, and the learning curve can be longer than expected.

The Impact of the Placement of the L5 Vertebra in Relation to the Intercrest Line on the Level of Disc Herniation.

AIM: To determine whether there is a correlation between a deeply seated L5 vertebra in relation to the intercrest line (ICL) and the level of degeneration of lumbar discs. MATERIAL AND METHODS: The study included 152 patients who underwent surgery for lumbar disc herniation. After analyzing the radiographs, the patients were separated into two groups. Group 1 patients had an ICL that passed through the L4 corpus, and Group 2 patients had an ICL that passed through the L4-5 disc distance or the L5 vertebra. Group 1 patients were classified as having a deeply seated L5 vertebra, while Group 2 patients were classified as not having a deeply seated L5 vertebra. RESULTS: The study found that male patients had a significantly higher incidence of a deeply seated L5 vertebra compared to female patients (p=0.003). Patients who underwent surgery at the L4?5 level exhibited disc heights that were notably higher than those who underwent surgery at the L5-S1 level. In Group 1, 68% of the patients had surgery at the L4-5 level, compared to only 41.7% in Group 2 (p=0.009). CONCLUSION: When investigating the effects of the position of the L5 vertebra in relation to the ICL at the L4-5 and L5-S1 disc levels, the study found that having a deeply seated L5 vertebra protected against L5-S1 disc herniation and that L4-5 disc herniation was more common in these patients. This is believed to be due to the L5?S1 segment being less mobile when the L5 vertebra is deeply seated.

Comparing Quality of Life: Discectomy Surgery versus Epidural Corticosteroid Injection for Lumbar Disc Herniation.

BACKGROUND: Selecting an efficient treatment for patients with radiculopathy caused by lumbar disc herniation (LDH) unresponsive to conservative management remains a challenging task under investigation, yielding varying results. This study aims to compare the outcomes of the 2 most prevalent invasive treatments. METHODS: In this retrospective longitudinal study, we enrolled patients with confirmed refractory symptomatic LDH who sought treatment at Valiasr Hospital and underwent either discectomy surgery or epidural steroid injection (ESI) between 2019 and 2022. The outcome measures included pain intensity using the Visual Analog Scale (VAS) and quality of life (QoL) using the SF-36 questionnaire. RESULTS: A total of 202 individuals (112 in the discectomy group and 90 in the ESI group) consisting of 90 males and 112 females, with a mean age of 50.9 ± 13.5 years, underwent analysis. In the univariate analysis, QoL scores were significantly higher in the discectomy group (57.4 ± 2.4) compared to the ESI group (44.2 ± 2.4) (P < 0.01). Furthermore, the surgery group exhibited a significantly greater reduction in the Leg VAS score after treatment compared to the ESI group (mean difference: -2.59, 95% confidence interval (CI): -3.45 to -1.70, P < 0.01). After adjusting for the most important confounding variables using multiple linear regression analysis, the association between surgery and higher QoL scores remained statistically significant (Unstandardized Coefficients B = 7.65, 95% CI: 0.55, 14.76, P = 0.03). CONCLUSIONS: Our findings indicate that discectomy surgery has a more pronounced effect on patient outcomes and is a preferable treatment option for LDH patients.

Optimizing prediction accuracy for early recurrent lumbar disc herniation with a directional mutation-guided SVM model.

Percutaneous endoscopic lumbar discectomy (PELD) is one of the main means of minimally invasive spinal surgery, and is an effective means of treating lumbar disc herniation, but its early recurrence is still difficult to predict. With the development of machine learning technology, the auxiliary model based on the prediction of early recurrent lumbar disc herniation (rLDH) and the identification of causative risk factors have become urgent problems in current research. However, the screening ability of current models for key factors affecting the prediction of rLDH, as well as their predictive ability, needs to be improved. Therefore, this paper presents a classification model that utilizes wrapper feature selection, developed through the integration of an enhanced bat algorithm (BDGBA) and support vector machine (SVM). Among them, BDGBA increases the population diversity and improves the population quality by introducing directional mutation strategy and guidance-based strategy, which in turn allows the model to secure better subsets of features. Furthermore, SVM serves as the classifier for the wrapper feature selection method, with its classification prediction results acting as a fitness function for the feature subset. In the proposed prediction method, BDGBA is used as an optimizer for feature subset filtering and as an objective function for feature subset evaluation based on the classification results of the support vector machine, which improves the interpretability and prediction accuracy of the model. In order to verify the performance of the proposed method, this paper proves the performance of the model through global optimization experiments and prediction experiments on real data sets. The accuracy of the proposed rLDH prediction model is 93.49% and sensitivity is 88.33%. The experimental results show that Level of herniated disk, Modic change, Disk height, Disk length, and Disk width are the key factors for predicting rLDH, and the proposed method is an effective auxiliary diagnosis method.

Long-term Outcome of Isobar TTL System for the Treatment of Lumbar Degenerative Disc Diseases.

OBJECTIVE: The Isobar TTL dynamic fixation system has demonstrated favorable outcomes in the short-term treatment of lumbar degenerative disc diseases (LDDs). However, there is a paucity of extensive research on the long-term effects of this system on LDDs. This study aimed to evaluate the long-term clinical and radiological outcomes of patients with LDDs who underwent treatment utilizing the Isobar TTL dynamic fixation system. METHODS: The study analyzed the outcomes of 40 patients with LDDs who underwent posterior lumbar decompression and received single-segment Isobar TTL dynamic internal fixation at our hospital between June 2010 and December 2016. The evaluation of clinical therapeutic effect involved assessing postoperative pain levels using the visual analogue scale (VAS) and Oswestry disability index (ODI), both before surgery, 3 months after, and the final follow-up. To determine the preservation of functional motion in dynamically stable segments, we measured the range of motion (ROM) and disc height of stabilized and adjacent segments preoperatively and during the final follow-up. Additionally, we investigated the occurrence of adjacent segment degeneration (ASD). RESULTS: Forty patients were evaluated, with an average age of 44.65 years and an average follow-up period of 79.37 months. Fourteen patients belonged to the spondylolisthesis group, while the remaining 26 were categorized under the stenosis or herniated disc group. The preoperative ROM of the stabilized segment exhibited a significant reduction from 8.15° ± 2.77° to 5.00° ± 1.82° at the final follow-up (p < 0.001). In contrast, there was a slight elevation in the ROM of the adjacent segment during the final follow-up, increasing from 7.68° ± 2.25° before surgery to 9.36° ± 1.98° (p < 0.001). The intervertebral space height (IH) in the stabilized segment exhibited a significant increase from 10.56 ± 1.99 mm before surgery to 11.39 ± 1.90 mm at the one-week postoperative follow-up (p < 0.001). Conversely, there was a notable decrease in the IH of the adjacent segment from 11.09 ± 1.82 mm preoperatively to 10.86 ± 1.79 mm at the one-week follow-up after surgery (p < 0.001). The incidence of ASD was 15% (6/40) after an average follow-up period of 79.37 months, with a rate of 15.38% (4/26) in the stenosis or herniated disc group and 14.29% (2/14) in the spondylolisthesis group; however, no statistically significant difference was observed in the occurrence of ASD among these groups (p > 0.05). CONCLUSION: The Isobar TTL dynamic fixation system is an effective treatment for LDDs, improving pain relief, quality of life (QoL) and maintaining stabilized segmental motion. It has demonstrated excellent long-term clinical and radiographic results.

Comparison of the Medium-term Outcomes of Anterior Lumbar Discectomy and Fusion with Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Retrospective Cohort Study.

OBJECTIVE: Lumbar degenerative diseases (LDDs) with huge herniation in the left lateral recess or central canal present challenges for oblique lateral lumbar interbody fusion (OLIF) or endoscope-assisted OLIF procedures. Currently, minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is the primary approach for this issue. This study aims to provide a standardized technical description of the anterior lumbar discectomy and fusion (ALDF) and evaluate the medium-term clinical effectiveness of both ALDF and MIS-TLIF techniques. METHODS: A retrospective review was performed on LDDs who underwent ALDF and MIS-TLIF surgery from January 2018 to January 2020. The evaluation encompassed various clinical outcomes, such as the visual analogue scale (VAS) scores for back pain and leg pain (VAS-back, VAS-leg), the Oswestry disability index (ODI), the 36-item short-form health survey mental component summary (SF-36 MCS), and the physical component summary (SF-36 PCS). Additionally, radiological parameters, including disc height (DH), segmental disk angle (SDA), lumbar lordosis (LL), and cross-sectional area (CSA), were assessed. Data including radiculopathy, estimated blood loss, operation time, time of getting out of bed, fusion rate, and complications were recorded. Student's independent samples t test and Pearson's chi-square test were used to compare the differences between groups. RESULTS: In total, 47 patients were treated by ALDF and 48 patients were treated by MIS-TLIF. The ALDF group exhibited statistically significant lower estimated blood loss and earlier time of getting out of bed compared to the MIS-TLIF group (p < 0.05). The ALDF group demonstrated lower VAS-back scores and a higher remission rate of low back pain 3 years after the surgery (p < 0.05). During the entire follow-up period, the ALDF group exhibited higher increases in DH and SDA compared to the MIS-TLIF group (p < 0.05). At 6 months, the fusion rate in the ALDF group was significantly higher than in the MIS-TLIF group (p < 0.05). The comparison revealed no statistically significant differences in complication rates between the two groups (p > 0.05). CONCLUSION: The ALDF could be considered as a viable surgical alternative for the treatment of LDDs that necessitate ventral neural direct decompression. ALDF exhibited favorable medium-term outcomes in patients with LDDs, displaying advantages in facilitating expedited recovery, enhancing radiographic outcomes, and elevating the remission rate of low back pain. Although ALDF presents slightly higher complication rates compared to MIS-TLIF, it does not adversely affect clinical outcomes.

Modified Percutaneous Endoscopic Interlaminar Discectomy through the Near-spinous Process Approach for L4/5 Disc Herniation: A Retrospective Clinical Study.

OBJECTIVE: Compared with traditional open surgery, percutaneous endoscopic lumbar discectomy (PELD) has the advantages of less trauma, faster recovery, and less postoperative pain, so it has been widely used in the field of spinal surgery. However, it still has the defect of intraoperative fluoroscopy occurrences, complications, and even the risk of damage to the spinal cord and nerve. This study aims to compare the clinical efficacy of modified percutaneous endoscopic interlaminar discectomy (MPEID) with percutaneous endoscopic transforaminal discectomy (PETD) in treating L4/5 lumbar disc herniation (LDH) and to evaluate the effectiveness and safety of MPEID. METHODS: Thirty-four L4/5 LDH patients treated at the Second Affiliated Hospital of Nanchang University from June 2020 to June 2021 were studied retrospectively. Seventeen underwent MPEID and seventeen PETD. Variables analyzed included demographics, operative duration, intraoperative fluoroscopy occurrences, and surgical outcomes. Effectiveness was evaluated using the visual analogue scale (VAS), Oswestry disability index (ODI), and modified MacNab criteria. Lumbar Magnetic Resonance Imaging (MRI) was used to assess radiological outcomes. A paired t-test was performed to compare intragroup pre- and postoperative clinical data, VAS, and ODI scores. RESULTS: The average operative time in PETD group was 91.65 ± 14.04 min, and the average operative time in MPEID group was 65.41 ± 12.61 min (p < 0.001). In PETD group, the fluoroscopy occurrences averaged 9.71 ± 1.05 times, with fluoroscopy occurrences averaging 6.47 ± 1.00 times (p < 0.001) in MPEID group. At 12 months follow-up, the clinical effect showed significant improvement in both two groups. The MPEID group showed a decrease in average VAS-back score from 5.41 ± 2.18 to 1.76 ± 1.09 (p < 0.001) and VAS-leg score from 6.53 ± 1.66 to 0.82 ± 0.64 (p < 0.001). The ODI scores decreased from 51.35 ± 10.65 to 11.71 ± 2.91 (p < 0.001). In the PETD group, the VAS-back score decreased from 4.94 ± 1.98 to 2.06 ± 1.25 (p < 0.001), VAS-leg score from 7.12 ± 1.73 to 1.12 ± 0.60 (p < 0.001), and ODI scores from 48.00 ± 11.62 to 12.24 ± 2.56 (p < 0.001). According to the modified MacNab criteria, MPEID had 15 excellent and two good results; PETD had 12 excellent and 5 good (p = 0.23). No nerve root injuries, dural tears, or significant complications were reported. CONCLUSION: MPEID and PETD effectively treat L4/5 LDH, with MPEID showing shorter operative times and fewer fluoroscopies. Furthermore, the MPEID group can provide excellent clinical efficacy as the PETD group in the short term.

Effects of propofol, desflurane, and spinal anesthesia on intraocular pressure during lumbar disc herniation surgery: a randomized controlled study.

OBJECTIVE: This study aims to evaluate the effects of total intravenous anesthesia (propofol), volatile anesthesia (desflurane), and spinal anesthesia on intraocular pressure (IOP) during lumbar disc herniation surgery in the prone position. PATIENTS AND METHODS: This randomized controlled trial was conducted between January 2022 and January 2023. The study included 75 patients with lumbar disc herniation between the ages of 18-75, with the American Society of Anesthesiologists (ASA) 1-2. The patients were randomly divided into 3 groups: propofol, desflurane, and spinal. IOP was measured at 5-time points throughout surgery, including baseline (T1), 10 minutes after anesthesia (T2), 10 minutes after prone positioning (T3: early prone), 30 minutes after prone positioning (T4: late prone), and 10 minutes after returning to the supine position (T5). Hemodynamic parameters were measured at these time points. Hemoglobin and hematocrit values were measured preoperatively and on the first postoperative day. RESULTS: There were 25 patients in each group. The groups were similar in terms of all characteristics except for weight and body mass index, which were lower in the spinal group. Propofol recipients had significantly higher T3 (prone) IOP compared to desflurane recipients (p = 0.001). We found no significant differences between groups in terms of T1, T2, T4, and T5 IOP. Multivariable linear regression revealed that diabetes mellitus (p = 0.016) and high T1 IOP (p = 0.001) were independently associated with higher T3 IOP. In addition, we found that the desflurane (p < 0.001) and spinal (p = 0.002) groups had significantly lower T3 IOP compared to propofol recipients after adjusting for diabetes mellitus and T1 IOP. CONCLUSIONS: Our findings suggest that volatile anesthesia (desflurane) and spinal anesthesia are linked to lower IOP in the prone position among patients undergoing spinal surgery, in comparison to those receiving total intravenous anesthesia. There is a need to test the results with more comprehensive, population-based studies in different patient groups. ClinicalTrials gov ID: NCT06070480.

[Molecular mechanism of residual lumbago and leg pain after transforaminal endoscopic treatment of lumbar disc herniation].

OBJECTIVE: To observe the residual of lumbago and leg pain with contained type （CT） and non-contained type （NCT） lumbar disc herniation （LDH） after transforaminal endoscopic treatment, and to explore the role of hypoxia-inducible factor-1α（HIF-1α） and transient receptor potential vanillate 1（TRPV1） pathway. METHODS: A total of 68 single-segment LDH patients were selected from July 2021 to October 2022, including 44 males and 24 females；aged 26 to 67 years old with an average of（43.63±11.94） years old；course of disease was 4 to 36 （18.91±10.34） months；body mass index was （24.45±4.00） kg·m-2；there were 7 cases of L3,4 segments, 32 cases of L4,5 segments, and 29 cases of L5S1 segments. All of them were performed with percutaneous intervertebral endoscopic extraction of nucleus pulposus and were divided into contained group（CT group） and non-contained group （NCT group） with 34 cases respectively according to the integrity of outer layer of fibrous annulus observed during operation. A total of 17 patients who underwent open surgery for scoliosis or vertebral fracture were selected as control group, including 12 males and 5 females；aged 21 to 65 years old with an average of （39.41±12.80） years old；body mass index was （24.86±4.11） kg·m-2. The relative mRNA expression quantity of HIF-1α, TRPV1 in nucleus pulposus were measured by quantitative real-time PCR. The contents of neurokinin 1 receptor （NK1R）, nerve growth factor （NGF）, vascular endothelial growth factor （VEGF） in nucleus pulposus and the serum substance P （SP） and calcitonin gene-related peptide （CGRP） were detected by enzyme linked immunosorbent assay （ELISA）. The threshold of lumbar tenderness was detected by a pressure pain meter. The degree of lumbago and lumbar function were evaluated by visual analog scale （VAS） and Oswestry disability index （ODI） separately. The residual rate of postoperative lumbago and leg pain was assessed. RESULTS: The mRNA relative expression quantity of HIF-1α and TRPV1, and the contents of NK1R, NGF and VEGF in nucleus pulposus, and the levels of serum SP and CGRP before surgery in the NCT group were higher than those in the CT group（P<0.05）, and those in the CT group were higher than the control group（P<0.05）. At day 7 after surgery, the serum SP and CGRP levels, lumbago and leg pain VAS scores and lumbar ODI index in two LDH groups were lower than before surgery （P<0.05）, and those in the NCT group were higher than the CT group（P<0.05）, and the threshold of lumbar tenderness in the NCT group was lower than the CT group（P<0.05）. The differences of lumbago and leg pain VAS scores, lumbar ODI index and lumbar tenderness threshold between preoperative and postoperative 7 days in the NCT group were lower than those in the CT group（P<0.05）. The residual rate of lumbago and leg pain at 7 days after surgery in the NCT group was higher than that in the CT group（P<0.05）. CONCLUSION: HIF-1α and TRPV1 pathway promoted the excessive production of NGF, VEGF, NK1R in nucleus pulposus and serum neuropeptides SP and CGRP, which may lead to the higher residual rate of lumbago and leg pain with non-contained lumbar disc herniation postoperative.

Full-Endoscopic Foraminoplasty and Lumbar Discectomy for Single-Level Lumbar Disc Herniation.

The Transforaminal Endoscopic Surgical System (TESSYS) technique has gained popularity for the treatment of lumbar disc herniations. Foraminoplasty is the key procedure in TESSYS. However, it requires advanced skills and long-term learning, which hinder its widespread adoption among surgeons. Recently, the introduction of full-endoscopic solutions has made the process more manageable. The main difference from traditional single-portal endoscopic surgery is that full-endoscopic surgery is equipped with a larger working channel, allowing full visualization of foraminoplasty and decreasing reliance on intraoperative fluoroscopy. Recently, published studies have shown that full-endoscopic foraminoplasty and lumbar discectomy (FEFLD) could achieve comparable results to conventional microdiscectomy in terms of pain relief and functional outcomes, while enhancing postoperative recovery. This study describes the technique of FEFLD in detail, including every crucial step, such as patient positioning, puncture trajectory, endoscopic dissection of the superior articular process (SAP), endoscopic foraminoplasty, and more. We hope this will be helpful to beginners who wish to apply this approach.

A Comparison of Minimally Invasive Surgical Techniques and Standard Open Discectomy for Lumbar Disc Herniation: A Network Meta-analysis.

BACKGROUND: Lumbar disc herniation is a common spinal disease that causes low back pain; surgery is required when conservative treatment is ineffective. There is a growing demand for minimally invasive surgery in younger patient populations due to their fear of significant damage and a long recovery period following standard open discectomy. The development history of minimally invasive surgery is relatively short, and no gold standard has been established. OBJECTIVES: We aimed to find, via a network meta-analysis, the best treatment for low back pain in younger patient populations. STUDY DESIGN: Network meta-analysis. METHODS: The PubMed, Embase, Cochrane Library, and Web of Science databases were searched. Data quality was evaluated using RevMan 5.3 (The Nordic Cochrane Centre for The Cochrane Collaboration), while STATA 14.0 (StataCorp LLC) was used for the network meta-analysis and to merge data on the Visual Analog Scale (VAS) score, Oswestry Disability Index (ODI) score, complication, blood loss, reoperation rate, and function score. RESULTS: We included 50 randomized controlled trials, involving 7 interventions; heterogeneity and inconsistency were acceptable. Comparatively, microendoscopic discectomy and percutaneous endoscopic lumbar discectomy were the best surgical procedures from the aspects of VAS score and ODI score, while standard open discectomy was the worst one from the aspect of ODI score. Regarding complications, tubular discectomy was preferred with the fewest complications. Additionally, microendoscopic discectomy outperformed other surgical procedures in reducing blood loss and reoperation rate. LIMITATIONS: First, follow-up data were not reported in all included studies, and the follow-up time varied from several months to 8 years, which affected the results accuracy of our study to some extent. Second, there were some nonsurgical factors that also affected the self-reported outcomes, such as rehabilitation and pain management, which also brought a certain bias in our study results. CONCLUSIONS: Compared to standard open discectomy, minimally invasive surgical procedures not only achieve satisfactory efficacy, but also microendoscopic discectomy and percutaneous endoscopic lumbar discectomy can obtain a more satisfactory short-term VAS score and ODI score. Microendoscopic discectomy has significant advantages in blood loss and reoperation rate, and tubular discectomy has fewer postoperative complications.