Epidural Versus Local Anesthesia for Percutaneous Endoscopic Lumbar Discectomy: A Systematic Review and Meta-Analysis.

STUDY DESIGNS: Systematic Review. OBJECTIVE: To examine the impact of anesthesia type on patient-reported outcomes (PROs) and complications after percutaneous endoscopic lumbar discectomy (PELD). SUMMARY OF BACKGROUND DATA: A significant advantage of PELD involves the option to use alternative sedation to general anesthesia (GA). Two options include local anesthesia (LA) and epidural anesthesia (EA). While EA is more involved, it may yield improved pain control and surgical results compared with LA. However, few studies have directly examined outcomes for PELD after LA versus EA, and it remains unknown which technique results in superior outcomes. MATERIALS AND METHODS: A systematic review and meta-analysis of the PubMed, EMBASE, and SCOPUS databases examining PELD performed with LA or EA from inception to August 16, 2021 were conducted. All studies reported greater than 6 months of follow-up in addition to PRO data. PROs, including visual analog scale (VAS)-leg/back, and Oswestry Disability Index (ODI) scores were collected. Complications, recurrent disk herniation, durotomy, and reoperation rates, as well as surgical data, were recorded. All outcomes were compared between pooled studies examining LA or EA. RESULTS: Fifty-six studies consisting of 4465 patients (366 EA, 4099 LA) were included. Overall complication rate, durotomy rate, length of stay, recurrent disk herniation, and reoperation rates were similar between groups. VAS back/leg and ODI scores were all significantly improved at the first and last follow-up appointments in the LA group. VAS leg and ODI scores were significantly improved at the first and last follow-up appointments in the EA group, but VAS back was not. CONCLUSIONS: EA can be a safe and feasible alternative to LA, potentially minimizing patient discomfort during PELD. Conclusions are limited by a high level of study bias and heterogeneity. Further investigation is necessary to determine if PELD under EA may have greater short-term PRO benefits compared with LA.

Independent reliability and availability analyses of modified classification for migrated lumbar disc herniation.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of this study was to evaluate the reliability of modified classification system of migrated nucleus pulposus and its clinical application value. METHODS: We retrieved 1000 lumbar MRI of different patients in Hangzhou Hospital of Traditional Chinese Medicine from January 2016 to December 2019 for interpretation, and screened 105 migrated lumbar MRI for inclusion in the study. Three spinal surgeons made classification according to the modified classification method. Two weeks later, the sorting data of the patients were shuffled and the classification was judged by three doctors again. The consistency and repeatability of the improved classification were evaluated by Kappa coefficient. The general data of the included patients were collected. The patients were followed up for 2 years, and the risk factors of surgical treatment of patients with migrated lumbar disc herniation were analyzed. The treatment plan, surgical approach, operation time, VAS score, ODI score and other relevant data of the included patients were collected to evaluate the guiding effect of the classification system on clinical practice. RESULTS: In this study, the incidence of migrated lumbar disc herniation was about 10.5%, and most of the patients were male. Patients with higher BMI are more likely to develop this disease. Our study confirmed that the modified classification has moderate to high confidence. During the 2-year follow-up period, 66 patients (62.9%) were treated conservatively, and the patients with conservative treatment were mainly A2 and B2 type (59.1%). Thirty-nine patients (37.1%) underwent surgical treatment. The patients recovered well after operation, and the low back pain and ODI index were significantly improved at 1 year after operation (P < 0.05). We suggest that type A1 and B1 migrated nucleus pulposus can be removed by posterior approach. For type A2, B2, C1, C2, the lateral approach is recommended to remove the nucleus pulposus directly. Logistic regression and ROC analysis showed that disease duration (≥ 1 year) and BMI (≥ 24) maybe were risk factors for surgical treatment of patients with migrated lumbar disc herniation. CONCLUSION: The modified classification has good reliability. In the current study, the experience level of spine surgeons does not affect the reliability of the classification system. Our study confirmed that this classification has a good reference value for guiding the treatment plan and the choice of surgical approach.

Transforaminal Versus Interlaminar Approach of Full-Endoscopic Lumbar Discectomy Under Local Anesthesia for L5/S1 Disc Herniation: A Randomized Controlled Trial.

BACKGROUND: Local anesthesia is feasible for both transforaminal and interlaminar approaches in percutaneous endoscopic lumbar discectomy (PELD). However, the optimal approach for PELD has not yet been established at the L5/S1 segment under local anesthesia with 1% lidocaine. OBJECTIVES: In this study, we compared the transforaminal approach with the interlaminar approach of PELD under local anesthesia for L5/S1 disc herniation (DH). STUDY DESIGN: This was a prospective randomized clinical trial. METHODS: From January 2019 to March 2020, 91 consecutive patients with L5/S1 DH who planned to undergo PELD in our unit were randomized to the transforaminal endoscopic lumbar discectomy (TELD, n = 46) or interlaminar endoscopic lumbar discectomy (IELD, n = 45). Both procedures were performed under local anesthesia with 1% lidocaine. The clinical outcomes were assessed as the Visual Analog Scale (VAS) score, Oswestry Disability Index (ODI) score, and modified MacNab criteria. Patient satisfaction surveys and surgical complications were also recorded and analyzed. RESULTS: Compared to the IELD group, the TELD group had a shorter operative time and postoperative bed rest time (P < 0.001) but a longer radiation time (P < 0.001) and lower VAS scores for intraoperative back pain (P < 0.001) and leg pain (P < 0.001). At the postoperative follow-up, there were no significant differences between the 2 groups in the VAS scores, ODI scores, or modified MacNab criteria. The surveys showed a significantly higher satisfaction rate in the TELD group than in the IELD group (P = 0.014). Six patients in the IELD group (13.3%) needed extra intravenous injections of sufentanil because of intense pain during the procedure. In the IELD group, there were 2 cases of neuropathic pain after surgery. LIMITATIONS: Due to the study was included in a single spine center with a relatively small population and its relatively short-term follow-up, the study is not generalizable. CONCLUSIONS: Both TELD and IELD can provide good clinical outcomes for L5/S1 DH under local anesthesia with 1% lidocaine. TELD was superior to IELD in terms of surgical-related experience and complications.

Transforaminal Full-endoscopic Discectomy for Gas-containing Herniated Nucleus Pulposus at L5-S1 Under Local Anesthesia†:†A Case Report.

The vacuum phenomenon is often observed in degenerative disc disease, whereas gas-containing disc herniation is relatively rare. Full-endoscopic discectomy at the lumbar spine level via a transforaminal approach, which was established and subsequently refined over the last two decades, requires only an 8-mm skin incision and causes minimal damage to the paravertebral muscles. Foraminoplasty, performed with a high-speed drill, is a useful technique to enlarge the foramen, especially when applied at the L5-S1 level, where the trajectory is limited because of anatomical structures such as the iliac crest. Here, we report a case of gas-containing lumbar disc herniation at L5-S1 that was successfully treated by transforaminal full-endoscopic discectomy. The patient was a 62-year-old man with low back pain and pain in the plantar aspect of the right great toe. Magnetic resonance and computed tomography scans demonstrated gas-containing lumbar disc herniation at L5-S1 on the right. Following foraminoplasty, transforaminal full-endoscopic lumbar discectomy was successfully performed under local anesthesia. The patient's symptoms improved immediately after the surgery. Transforaminal full-endoscopic surgery can be effective and minimally invasive even when performed for gas-containing disc herniation. J. Med. Invest. 69 : 328-331, August, 2022.

Determination of Patient Acceptable Symptom State for the Oswestry Disability Index Score in Patients Who Underwent Minimally Invasive Discectomy for Lumbar Disc Herniation: 2-Year Follow-up Data from a Randomized Controlled Trial.

OBJECTIVE: We aim to determinate the patient acceptable symptom state (PASS) for the Oswestry Disability Index (ODI) score in patients undergoing minimally invasive discectomy for the treatment of lumbar disc herniation. METHODS: A post hoc analysis of prospectively collected, 2-year follow-up data was conducted. The anchor for determination of PASS was the European Quality of Life Visual Analog Scales question, and the Pearson correlation test was performed to evaluate its validity. The receiver operating characteristics (ROC) curve analysis was conducted to determine the PASS thresholds for ODI and its discriminative ability assessment. Sensitivity analyses were also carried out for alternative definition of PASS, different follow-up periods, and different subgroups. RESULTS: A total of 222 patients (92.1%) completed the 2-year follow-up, 92.8% of whom considered their state to be acceptable. The area under the ROC curve (AUC) were all >0.8, indicating a high discriminative ability. The PASS threshold for the ODI was suggested to be 5 at 6 months (AUC: 0.80; sensitivity: 79.0%, specificity: 73.7%) and 2 years (AUC: 0.98; sensitivity: 90.3%, specificity: 100%) postoperatively. Despite some variations found in different body mass index and baseline ODI subgroups, sensitivity analysis showed that the above-mentioned threshold was robust. CONCLUSIONS: An ODI of 5 was noted to be the PASS threshold for patients received minimally invasive discectomy for the treatment of LDH. This ODI threshold was robust, and therefore recommended as the ultimate goal of minimally invasive treatment for LDH, which can help to present results of clinical research at an individual level.

Comparing the Effectiveness and Safety Between Local Anesthesia versus Epidural Anesthesia for Percutaneous Transforaminal Endoscopic Discectomy: A Systematic Review and Meta-Analysis.

OBJECTIVE: The objective of this study was to compare the effectiveness and safety of local anesthesia (LA) and epidural anesthesia (EA) for percutaneous transforaminal endoscopic discectomy (PTED) and provide reference data for clinical decision-making. METHODS: We searched PubMed, EMBASE, the Cochrane library, Web of Science, Medline, Science Direct, and China National Knowledge Infrastructure from inception to March 2022 to identify randomized and nonrandomized controlled trials comparing LA and EA for PTED. Studies that assessed at least 2 of the following indicators were considered eligible: surgical duration, X-ray exposure time, satisfaction rate, visual analog scale scores for pain, Oswestry Disability Index, and complications. Meta-analysis was conducted using Review Manager 5.3.3 software. RESULTS: Five randomized controlled trials and 5 retrospective cohort studies involving a total of 1660 patients were included. The LA and EA groups included 803 and 857 patients, respectively. Meta-analysis revealed significant intergroup differences in the intraoperative lumbar visual analog scale scores (P < 0.00001) and anesthesia satisfaction rate (P < 0.00001). There were no significant intergroup differences in the surgical duration, X-ray exposure time, postoperative Oswestry Disability Index, and complication rate. CONCLUSIONS: EA is as safe as LA and produces better anesthetic effects than LA in patients undergoing PTED. Therefore, EA should be promoted as a reliable anesthetic technique for PTED.

A retrospective comparative study of local anesthesia only and local anesthesia with sedation for percutaneous endoscopic lumbar discectomy.

It is still an unsolved problem to achieve both immediate intraoperative feedback and satisfactory surgical experience in percutaneous endoscopic lumbar discectomy under local anesthesia for lumbar disk herniation (LDH) patients. Herein, we compared the analgesic and sedative effects of local anesthesia alone and local anesthesia with conscious sedation in LDH patients during percutaneous endoscopic lumbar discectomy. Ninety-two LDH patients were enrolled and divided into the following groups: control group (Con Group), dexmedetomidine group (Dex Group), oxycodone group (Oxy Group), and dexmedetomidine + oxycodone group (Dex + Oxy Group). Various signs, including mean arterial pressure (MAP), heart rate (HR), pulse oximeter oxygen saturation (SpO2) and Ramsay score, were compared before anesthesia (T1), working cannula establishment (T2), nucleus pulposus removal (T3), and immediately postoperation (T4). Clinical outcomes, including VAS score, operation time, hospitalization period, Macnab criteria, and SF-36 score, were also evaluated. The Dex + Oxy Group showed the most stable MAP and HR at T2 and T3 in all groups. The clinical outcomes, such as VAS, hospitalization period, Macnab criteria, and SF-36 score, have no significant differences among groups (p > 0.05). Local anesthesia combined with conscious sedation is a safe and effective method to improve the surgical experience and achieve satisfying clinical outcomes for LDH patients during percutaneous endoscopic lumbar discectomy.

Percutaneous transforaminal endoscopic discectomy combined with acupuncture for lumbar disc herniation: A protocol for systematic review and meta-analysis.

BACKGROUND: Lumbar disc herniation (LDH) is a common orthopedic disease, which is one of the main causes of global chronic pain and motor function defect. For intractable LDH, the surgical treatment of percutaneous transforaminal endoscopic discectomy (PTED) is often used in clinical practice. Although the operation is relatively mature, there may still be some limitations and surgical risks delaying the recovery process of patients. Some studies have found that the combination of acupuncture therapy and PTED can bring more benefits to patients, but these conclusions are still lack of evidence support. Therefore, this study will adopt the method of meta-analysis to estimate the effectiveness and safety of acupuncture combined with PTED in patients with LDH, in order to provide a basis for clinical decision-making. METHODS: This study will conduct a systematic search of the following databases: the Chinese databases China National Knowledge Infrastructure, formerly Chinese Biomedical Database, Wanfang Data, Chongqing VIP Database for Chinese Technical Periodicals, the PubMed, Medline, Embase, Web of Science and The Cochrane library, from their inception to December 1, 2022. In addition, we will search their references to avoid missing other eligible studies. The language will be limited to English and Chinese. RevMan 5.4 will be used to perform the meta-analysis. And GRADE Profiler software will be used to rate the quality of evidence. RESULTS: The results will be submitted to a peer-reviewed journal. CONCLUSION: This study can provide evidence support for acupuncture combined with PTED in the treatment of LDH.

Gradient local anesthesia for percutaneous endoscopic interlaminar discectomy at the L5/S1 level: a feasibility study.

BACKGROUND: During the process of shearing the ligamentum flavum, rotating the working channel, and manipulating the annulus fibrosis, the sinuvertebral nerve and the spinal nerve root can be irritated, inducing intolerable back and leg pain. Thus, general anesthesia is recommended and well accepted by most surgeons when performing percutaneous endoscopic lumbar discectomy (PELD) via the interlaminar approach. The aim of our study was to explore the efficacy and safety of percutaneous endoscopy interlaminar lumbar discectomy with gradient local anesthesia (LA) in patients with L5/S1 disc herniation. METHODS: This retrospective study was conducted between December 2017 and June 2018. The study included 50 consecutive patients who met the study criteria, had single-level L5/S1 disc herniation, and underwent PELD via the interlaminar approach under gradient LA. Different concentrations of local anesthetic compound (LAC) were injected into different tissues inside and outside the ligamentum flavum to complete gradient LA. The evaluation criteria included the intraoperative satisfaction score, visual analog scale (VAS) score, Oswestry Disability Index (ODI), complications, and adverse reactions. RESULTS: The intraoperative satisfaction score was consistently over 7, with an average score of 9.3 ± 0.7, indicating that LAC can achieve satisfactory pain control throughout the PELD operation without additional anesthesia. The postoperative VAS score and ODI were dramatically improved at each follow-up interval (P < 0.001, respectively). There was no serious complication such as dural rupture caused by puncture, dural laceration caused by manipulation under endoscopy, total spinal anesthesia, iatrogenic nerve root injury, epidural hematoma, infections, or local anesthetic-related adverse reactions. Three patients experienced transient postoperative dysesthesia of the lower limbs that gradually recovered within 24 h. CONCLUSIONS: Gradient local anesthesia can satisfactorily and safely control intraoperative pain during the PELD via the interlaminar approach. It can not only improve intraoperative satisfaction, but also reduce local anesthesia-related adverse reactions and surgery-related complications.

Stepwise Local Anesthesia for Percutaneous Endoscopic Interlaminar Discectomy: Technique Strategy and Clinical Outcomes.

BACKGROUND: Due to suboptimal pain control under conventional local anesthesia, percutaneous endoscopic interlaminar discectomy is typically performed under general anesthesia. The purpose of this study was to develop a stepwise approach of local anesthesia for endoscopic interlaminar discectomy and evaluate its efficacy. METHODS: A stepwise local anesthesia was developed, which mainly includes 3 steps: conventional local anesthesia from skin to laminae, epidural injection, and nerve root block. From June 2015 to May 2017, consecutive patients who underwent endoscopic interlaminar discectomy were included. Local anesthesia or general anesthesia was used based on patients' preference. Anesthetic effectiveness was evaluated as excellent, good, or poor, and adverse events were recorded. Hospitalization expense was compared between the 2 groups. Clinical outcomes were assessed using the Visual Analog Scale and the Oswestry Disability Index. RESULTS: There were 98 patients included in the study. Among them, 48 received stepwise local anesthesia and the other 50 received general anesthesia. In the stepwise local anesthesia group, 40 (83.3%) patients rated anesthetic effectiveness as excellent, 7 (14.6%) as good, and 1 (2.1%) as poor. Nine patients had complications that may be associated with local anesthesia, including dyspnea, temporary paresis of legs, and temporary worsened dysesthesia or numbness in legs. After surgery, the patients' leg pain and Oswestry Disability Index significantly improved in both groups. On average, hospitalization expense was approximately 20% less when local anesthesia was used, as compared with using general anesthesia. CONCLUSIONS: The stepwise local anesthesia can achieve satisfactory pain control and seems to be a good choice for endoscopic interlaminar discectomy.

Percutaneous Endoscopic Interlaminar Lumbar Discectomy with Local Anesthesia for L5-S1 Disc Herniation: A Feasibility Study.

BACKGROUND: General anesthesia (GA), which is routinely applied in patients who undergo percutaneous endoscopic interlaminar lumbar discectomy (PEILD) of L5-S1 disc herniation, is closely associated with postoperative cognitive dysfunction (POCD) in the elderly. Local anesthesia (LA) is an alternative pain control protocol that has not yet been fully evaluated. OBJECTIVES: To evaluate the feasibility of LA in PEILD compared with GA. STUDY DESIGN: A retrospective study. SETTING: This study took place at the First Affiliated Hospital of Harbin Medical University. METHODS: A total of 120 patients (aged 60-85 years) diagnosed with L5-S1 disc herniation and with American Society of Anesthesiologists fitness grade I or II between March 2016 and August 2017 were enrolled in the current study. Patients were randomly divided into LA group and GA group. For LA, 0.25% lidocaine was injected layer-by-layer into skin, subcutaneous tissue, fasciae, lumbar facet joint, muscle, and ligamentum flavum followed by injection of 1.33% lidocaine into epidural space; for GA, propofol, sufentanil, and cisatracurium were infused intravenously at 1 to 2 mg/kg, 0.3 µg/kg, and 0.15 mg/kg, respectively. Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and MacNab Criteria (MNC) evaluated the feasibility of LA as pain control protocol in comparison to GA before and after operation. The development of POCD was assessed by the Mini-Mental State Examination 1 and 7 days postsurgery. Feasibility of LA as a pain control protocol was also evaluated by patient's willingness to receive the same surgical procedure immediately and 24 hours after the surgery, and intraoperative fluoroscopy use, blood loss, surgery duration, postoperative bed confinement, and duration and cost of hospital stay were also evaluated. RESULTS: Patients in both LA and GA groups had comparable VAS grade, ODI, and MNC pre- and post-PEILD, with significant pain reduction after operation. However, POCD developed only in GA group but not in LA group. In addition, compared with GA, LA group did not require postoperative bed confinement, had significantly shorter hospital stay, and lower hospital cost. Low intraoperative VAS grade and willingness to receive the same procedure reflected the acceptance of LA by patients. LIMITATIONS: The development of POCD was examined only 7 days after operation. The follow-up should be extended to 3 months and 2 years postoperation. CONCLUSIONS: LA has satisfactory pain control and low-risk of POCD in PEILD and is well accepted by patients. The benefits of LA are no postoperative bed confinement, faster recovery, shorter hospital stay, and lower hospital cost. KEY WORDS: L5-S1 disc herniation, older patients, percutaneous endoscopic interlaminar lumbar discectomy, local anesthesia, general anesthesia, postoperative cognitive dysfunction, American Society of Anesthesiologists grade, Oswestry Disability Index, MacNab Criteria, Mini-Mental State Examination.

Transforaminal percutaneous endoscopic discectomy for lumbar disc herniation in athletes under the local anesthesia.

BACKGROUND: Percutaneous endoscopic discectomy (PED) has been reported to be less invasive and effective procedure for lumbar disc herniation (LDH). Damage to the back muscle is considered minimal, which is particularly important for athletes. However, the results of PED for LDH in athletes have not been reported well. The purpose of this study was to evaluate the clinical outcomes of PED for LDH in athletes. METHODS: We retrospectively analyzed 21 athlete patients with LDH who had undergone PED. All patients received athletic rehabilitation immediately after surgery. The clinical outcomes were evaluated from the visual analogue scale (VAS) for leg pain and low back pain (LBP), the Oswestry Disability Index (ODI), complications and periods of return to sport. RESULTS: There were 18 men and 3 women, and the mean age at the time of surgery was 22.9 years (range: 15-43 years). The mean VAS scores for leg pain before and after surgery were 64.3 ± 2.7 mm and 12.4 ± 1.4 mm, respectively. The mean VAS scores for LBP before and after surgery were 62.1 ± 2.2 mm and 10.5 ± 1.1 mm, respectively. The mean ODI scores before and after surgery were 31.3 ± 14.0% and 14.6 ± 7.1%, respectively. The VAS for leg pain, as well as the LBP and ODI, significantly improved after surgery. There were no complications related to the surgery. Ninety-five percent (20/21) returned to play sports at the same performance level as before the procedure by an average of 9.2 weeks after PED. CONCLUSIONS: PED is a minimally invasive and effective procedure for patients with LDH, especially in athletes. Not only the patients' leg pain but also their discogenic LBP improved. PED has the benefits of preservation of normal posterior structures and a faster return to sports.

How I do it: percutaneous transforaminal endoscopic discectomy for lumbar disk herniation.

BACKGROUND: Percutaneous transforaminal endoscopic discectomy (PTED) has emerged as a less invasive technique to treat symptomatic lumbar disk herniation (LDH). PTED is performed under local anesthesia with the advantage of immediate intraoperative feedback of the patient. In this paper, the technique is described as conducted in our hospital. METHODS: PTED is performed under local anesthesia in prone position on thoracopelvic supports. The procedure is explained stepwise: e.g. marking, incision, introduction of the 18-gauge needle and guidewire to the superior articular process, introduction of the TomShidi needle and foraminotomy up to 9 mm, with subsequently removal of disk material through the endoscope. Scar size is around 8 mm. CONCLUSION: PTED seems a promising alternative to conventional discectomy in patients with LDH and can be performed safely.

Comparison of 3 Anesthetic Methods for Percutaneous Transforaminal Endoscopic Discectomy: A Prospective Study.

BACKGROUND: Percutaneous transforaminal endoscopic discectomy (PTED) under local anesthesia (LA) is growing popular in recent years because of its safety, effectiveness and increased patient demands for minimally invasive procedures. To avoid neural injuries, local anesthesia that can keep the patient conscious is recommended. However, many patients complain about the severe pain during surgery. Epidural anesthesia (EA) is an alternative choice. We put forward an anesthetic method that combined preemptive analgesia (PA) and local anesthesia. OBJECTIVES: The study aimed to assess the effectiveness of 3 methods of anesthesia for PTED, LA, EA and PA. STUDY DESIGN: A prospective study. METHODS: Three groups of patients were treated with standard PTED under LA, PA or EA, respectively. The data collected for analysis were operative time, x-ray exposure time, postoperative bed time, visual analog scale (VAS), Oswestry Back Pain Disability Index (ODI), the global outcome based on the Macnab outcome criteria, satisfaction rate of anesthesia, and complications. RESULTS: A total of 240 consecutive patients were enrolled in this study from January 2014 to December 2016. Among 3 groups, 1-week postoperatively VAS (back and leg) and ODI were improved compared with preoperative data, and the excellent/good rates were all above 90%. However, satisfaction rate of anesthesia showed significant differences among the 3 groups. PA and EA showed significantly better performance in pain management intraoperatively and 1 hour postoperatively. The operation time of group PA was the shortest and group EA was the longest. No severe neural injuries occurred in any of the 3 groups. Transient paresis of lower limbs occurred in all 3 groups and showed no significant differences. Decreased muscle strength of lower limbs postoperatively occurred in 2 patients in group EA. The incidence of nausea and vomiting postoperatively was significantly higher in group PA (6 cases, 7.50%). There were 3 cases of dysuria postoperatively in group EA (3.75%). LIMITATION: First, this is a single center study. Second, this study investigated the effects of anesthesia on perioperative period and the follow-up time was relatively short. Third, we choose morphine in group PA and there are other types of anesthetics which may be used in preemptive analgesia in further study. CONCLUSION: All 3 of these anesthetic methods are safe to avoid neural injuries. EA and PA showed better performance in pain management but had more anesthesia-related complications. KEY WORDS: Percutaneous transforaminal endoscopic discectomy (PTED), local anesthesia, epidural anesthesia, preemptive analgesia, morphine, ropivacaine, pain management, visual analog scale (VAS), Oswestry Back Pain Disability Index (ODI).

State-of-the-art transforaminal percutaneous endoscopic lumbar surgery under local anesthesia: Discectomy, foraminoplasty, and ventral facetectomy.

Transforaminal (TF) percutaneous endoscopic surgery for the lumbar spine under the local anesthesia was initiated in 2003 in Japan. Since it requires only an 8-mm skin incision and damage of the paravertebral muscles would be minimum, it would be the least invasive spinal surgery at present. At the beginning, the technique was used for discectomy; thus, the procedure was called PELD (percutaneous endoscopic lumbar discectomy). TF approach can be done under the local anesthesia, there are great benefits. During the surgery patients would be in awake and aware condition; thus, severe nerve root damage can be avoided. Furthermore, the procedure is possible for the elderly patients with poor general condition, which does not allow the general anesthesia. Historically, the technique was first applied for the herniated nucleus pulposus. Then, foraminoplasty, which is the enlargement surgery of the narrow foramen, became possible thanks to the development of the high speed drill. It was called the percutaneous endoscopic lumbar foraminoplasty (PELF). More recently, this technique was applied to decompress the lateral recess stenosis, and the technique was named percutaneous endoscopic ventral facetectomy (PEVF). In this review article, we explain in detail the development of the surgical technique of with time with showing our typical cases.

Comparison of the effects of local anesthesia and epidural anesthesia for percutaneous transforaminal endoscopic discectomy in elderly patients over 65 years old.

BACKGROUND: Local anesthesia (LA) is recommended for percutaneous transforaminal endoscopic discectomy (PTED) but clinical practice indicates that LA cannot achieve satisfactory pain management during PTED. OBJECTIVES: The study aimed to investigate the comparisons between LA and EA for PTED in elderly population over 65 years old. METHODS: We performed a retrospective analysis of patients over 65 years old received PTED from May 2013 to December 2014. And patients were divided into two groups according to the anesthesia method. The data collected for analysis including operative time, fluoroscopy time, postoperative bed time, visual analog scale (VAS), Oswestry Back Pain Disability Index (ODI), the global outcome based on the Macnab outcome criteria, satisfaction rate of anesthesia, and complications. RESULTS: A total of 132 consecutive patients were enrolled in this study. There were 65 patients in LA group and 67 patients in EA group. Compared to LA group, EA group had longer operative time (P < 0.001) and postoperative bed time (P < 0.001) but shorter fluoroscopy time, (P < 0.001), smaller VAS score of lumbar pain intraoperatively (P < 0.001), 1-h postoperatively (P < 0.001) and 1-week postoperatively (P < 0.001). Similarly, EA group had lower VAS score of leg pain intraoperatively (P < 0.001) and 1-h postoperatively (P < 0.001). In additions, higher satisfaction rate of anesthesia was observed in EA group (P = 0.029). CONCLUSIONS: EA and LA for PTED achieved comparable clinical outcomes in elderly population over 65 years old. However, compared to LA for PTED, EA had a better performance in pain management.

The effect of preoperative administration of morphine in alleviating intraoperative pain of percutaneous transforaminal endoscopic discectomy under local anesthesia: A STROBE compliant study.

Local anesthesia is routinely recommended for percutaneous transforaminal endoscopic discectomy (PTED). However, the intense intraoperative pain remains a serious problem. The purpose of the current study is to find a safe and effective method to alleviate the intense pain during PTED for lumbar disc herniation (LDH) under local anesthesia.This study retrospectively analyzed 63 LDH patients who accepted PTED under local anesthesia. Thirty-one patients received intramuscular injection of morphine before PTED, while the other 32 were not. The 10 points visual analogue scale (VAS) was used to assess the patients' maximum leg and back pain. Patients were asked to grade their experiences of surgery and anesthesia on a 5-point Likert-type scale after the surgery. Modified Mac Nab Criteria were used to evaluate the surgical outcomes after 3-month follow-up.The intraoperative VAS scores of patients who accepted preoperative intervention decreased significantly. The postoperative VAS scores of both groups showed no significance. Patients who received preoperative intervention reported a higher subjective satisfaction rate with the surgery experience. According to the Modified Mac Nab criteria, the surgical outcomes of both groups were similar through the 3-month follow-up. After injection of morphine, 4 patients complained nausea and 2 patients experienced vomiting.Preoperative intramuscular injection of morphine could reduce the patients' pain during the PTED surgery and improve the patients' satisfaction without affecting the surgical outcome. Except for a higher incidence of nausea and vomiting, this method is relatively safe and convenient.

The effect of percutaneous endoscopic lumbar discectomy under different anesthesia on pain and immunity of patients with prolapse of lumbar intervertebral disc.

OBJECTIVE: To explore the effect of percutaneous transforaminal endoscopic discectomy under different anesthesia on pain and immunity of patients with lumbar disc herniation. PATIENTS AND METHODS: 92 cases of patients with lumbar disc herniation in the Affiliated Hospital of Qingdao University from February 2015 to January 2016 were collected. These patients were randomly divided into control group and observation group (n = 46). Patients in the control group underwent percutaneous transforaminal endoscopic discectomy with the use of local anesthesia, while patients in the observation group used continuous epidural anesthesia. Oswestry Disability Index (ODI) and Visual Analogue Scale of Pain (VAS) were used to compare the surgical effect and the degree of pain of patients in the two groups. Adverse reactions (nausea, vomiting, dizziness, drowsiness) of patients in two groups were compared. T lymphocytes subset level (CD4+, CD8+) and inflammatory cytokines (IL-2, TNF) in the immune system were compared on the 1st, 3rd, and 10th day post-operatively. RESULTS: The pain degree of patients in the two groups had no significant difference before their operations (p > 0.05). The intraoperative pain rate of patients in the observation group was significantly lower than the control group (p < 0.05). Patients in both groups achieved a remarkable decrease of pain intensity on month 1 and month 3 post-operatively (p < 0.05). There is no significant difference between the two groups (p > 0.05). ODI scores of patients in the two groups had no significant difference pre-operatively (p > 0.05). Patients in both groups achieved a remarkable decrease of ODI scores after surgery (p < 0.05), and there is no significant difference between the two groups (p > 0.05). The occurrence of adverse reactions in the observation group was significantly lower than the control group (p < 0.05). On day 1 and 3 post-operatively, CD4+ and CD8+ levels of patients in both groups were lower than before operation, and data in the control group decreased more than the observation group (p < 0.05). IL-2 and TNF-α levels of patients in the two groups were significantly higher than pre-operatively, and data in the control group was higher than the observation group (p < 0.05). On day 10 post-operatively, all the indexes returned to the preoperative level. CONCLUSIONS: Both continuous epidural anesthesia and local anesthesia can reduce or avoid perioperative pain, but continuous epidural anesthesia has more advantages than local anesthesia, and it can improve the immune function for patients undergoing PTED for LDH.

Modified Percutaneous Lumbar Foraminoplasty and Percutaneous Endoscopic Lumbar Discectomy: Instrument Design, Technique Notes, and 5 Years Follow-up.

BACKGROUND: Conventional percutaneous endoscopic lumbar discectomy (PELD) with an "inside-outside" technique has 4.3% - 10.3% surgical failure rate, especially in central herniated discs (HDs), migrated HDs, and axillary type HDs. PELD with foraminoplasty has been used for complex HDs. Percutaneous lumbar foraminoplasty (PLF), which is performed with a trephine or bone reamer introduced over a guidewire without a protective working cannula in the original Tessys technique, can quickly cut the hypertrophied bony structure under fluoroscopic guidance, and risk injury to the exiting and traversing nerve roots. STUDY DESIGN: A prospective cohort study. SETTING: Hospital and outpatient surgical center. OBJECTIVE: To evaluate the outcome and safety of modified PLF-PELD with a specially designed instrument for complex uncontained lumbar HDs. METHOD: From April of 2007 to April of 2009, 148 patients with uncontained lumbar HDs were treated with modified PLF-PELD. Magnetic resonance imaging (MRI) checkup was performed the next morning after the operation. Outcomes of symptoms were evaluated by follow-up interviews at 3 months, 6 months, one year, and 5 years after surgery. Low back pain and leg pain were measured by visual analog scale (VAS) score (1 - 100). Functional outcomes were assessed by using the Oswestry Disability Index (ODI) and modified MacNab criteria. RESULTS: Follow-up data were obtained from 134 cases, including 14 cases on L3-4, 78 cases on L4-5, and 42 cases on L5-S1. One hundred-eight cases were prolapse type, while 26 cases were sequestration type. Pre-operative symptoms and deficits included nerve root dermatome hypoesthesia in 98 patients (73%), nerve root myotome muscle weakness in 32 patients (23%), and weakening or disappearance of tendon reflex in 43 patients (32%). No case required conversion to an open procedure during the surgery. Low back pain and leg pain were significantly relieved immediately after surgery in all patients. MRI examination showed adequate removal of HD in all patients. VAS scores and ODI values were significantly lower at all time points after surgery than before surgery. The percentage of pain relief in leg pain was significantly higher than that in low back pain (P < 0.01). But there was no significant correlation between duration of the preoperative symptoms and the percentage of pain relief. MacNab scores at 5 years after surgery were obtained from 134 patients. Seventy-five cases were rated "excellent"; 49 were rated "good," Five patients experienced heavier low back pain, thus being classified as "fair." Five cases with recurrence were rated "poor." Preoperative and postoperative (5 years follow-up) related nerve root function status was compared. Sensation and muscle strength recovered significantly (P < 0.01), while tendon reflex was not changed (P = 0.782). No patients had infections. Five patients were complicated with dysesthesia in distribution of the exiting nerve that was all operated at L5-S1. Complaints were reduced one week after treatment with medium frequency pulse electrotherapy. Five cases required a revision surgery after recurrence. LIMITATIONS: This is an observational clinical case series study without comparison. CONCLUSION: Modified PLF-PELD with a specially designed instrument is a less invasive, effective and safe surgery for complex uncontained lumbar DH.Key words: Lumbar disc herniation, minimally invasive treatment, foraminoplasty, percutaneous endoscopic lumbar discectomy.

Outcomes of percutaneous endoscopic lumbar discectomy via a translaminar approach, especially for soft, highly down-migrated lumbar disc herniation.

PURPOSE: This study reports a new approach for percutaneous endoscopic lumbar iscectomy (PELD), especially for soft, highly down-migrated lumbar disc herniation. METHODS: Seven patients with soft, highly down-migrated lumbar disc herniation who underwent PELD via a translaminar approach under local anaesthesia from January 2013 to June 2015, including five patients who underwent failed PELD in other hospitals, were retrospectively analyzed. Clinical outcomes were evaluated according to pre-operative and post-operative visual analogue scale (VAS) scores, Oswestry disability index (ODI) scores and post-operative magnetic resonance imaging (MRI). RESULTS: The highly down-migrated lumbar disc herniation was completely removed by PELD via a translaminar approach in seven patients, as confirmed by post-operative MRI. Leg pain was eased after removal of the disc migrations. The mean follow-up duration was 9.8 (range, 6-14) months. The mean pre-operative VAS was 7.6 ± 0.8 (range, 6-9), which decreased to 3.1 ± 1.5 (range, 2-5) at one week post-operatively and to 1.3 ± 0.8 (range, 0-3) by the last follow-up visit. The mean pre-operative ODI was 61.6 (range, 46-84), which decreased to 16.3 (range, 10-28) at the one month post-operative follow-up and to 8.4 (range, 0-14) by the last follow-up visit. No recurrence was observed in any of the seven patients during the follow-up period. CONCLUSION: PELD via a translaminar approach could be a good alternative option for the treatment of soft, highly down-migrated lumbar disc herniation.