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1.  Learning curve of full-endoscopic lumbar discectomy 
European Spine Journal  2012;22(4):727-733.
To report the learning curve of full-endoscopic lumbar discectomy for a surgeon naive to endoscopic surgery but trained in open microdiscectomy.
From July 2006 to July 2009, 57 patients underwent full-endoscopic lumbar discectomy and 66 underwent open microdiscectomy. The clinical results were evaluated with a visual analog scale (VAS) and the Oswestry Disability Index (ODI). Spearman’s coefficient of rank correlation (rho) was used to assess the learning curves for the transforaminal and interlaminar procedures of full-endoscopic lumbar discectomy.
After full-endoscopic lumbar discectomy, the VAS and ODI results of the patients followed up were comparable with those of open microdiscectomy. A steep learning curve was observed for the transforaminal procedure, but not the interlaminar procedure.
The learning curve of the transforaminal approach was steep and easy to learn, while the learning curve of the interlaminar approach was flat and hard to master.
PMCID: PMC3631049  PMID: 23076645
Learning curve; Disc herniation; Endoscopic lumbar discectomy; Transforaminal procedure; Interlaminar procedure
2.  Endoscopic discectomy of L5-S1 disc herniation via an interlaminar approach: Prospective controlled study under local and general anesthesia 
Open discectomy remains the standard method for treatment of lumbar disc herniation, but can traumatize spinal structure and leaves symptomatic epidural scarring in more than 10% of cases. The usual transforaminal approach may be associated with difficulty reaching the epidural space due to anatomical peculiarities at the L5–S1 level. The endoscopic interlaminar approach can provide a direct pathway for decompression of disc herniation at the L5–S1 level. This study aimed to evaluate the clinical results of endoscopic interlaminar lumbar discectomy at the L5–S1 level and compare the technique feasibility, safety, and efficacy under local and general anesthesia (LA and GA, respectively).
One hundred twenty-three patients with L5–S1 disc herniation underwent endoscopic interlaminar lumbar discectomy from October 2006 to June 2009 by two spine surgeons using different anesthesia preferences in two medical centers. Visual analog scale (VAS) scores for back pain and leg pain and Oswestry Disability Index (ODI) sores were recorded preoperatively, and at 3, 6, and 12 months postoperatively. Results were compared to evaluate the technique feasibility, safety, and efficacy under LA and GA.
VAS scores for back pain and leg pain and ODI revealed statistically significant improvement when they were compared with preoperative values. Mean hospital stay was statistically shorter in the LA group. Complications included one case of dural tear with rootlet injury and three cases of recurrence within 1 month who subsequently required open surgery or endoscopic interlaminar lumbar discectomy. There were no medical or infectious complications in either group.
Disc herniation at the L5–S1 level can be adequately treated endoscopically with an interlaminar approach. GA and LA are both effective for this procedure. However, LA is better than GA in our opinion.
PMCID: PMC3130490  PMID: 21748045
General anesthesia; interlaminar approach; local anesthesia; lumbar disc herniation; percutaneous endoscopic discectomy
3.  Objective assessment of reduced invasiveness in MED 
European Spine Journal  2005;15(5):577-582.
Microendoscopic discectomy (MED) has been accepted as a minimally invasive procedure for lumbar discectomy because of the small skin incision and short hospital stay required for this surgery. However, there are few objective laboratory data to confirm the reduced systemic responses in the early phase after this procedure. In order to substantiate the reduced invasiveness of MED compared to microdiscectomy (MD) or procedures involved in one-level unilateral laminotomy, the invasiveness of each surgical procedure was evaluated by measuring serum levels of biochemical parameters reflective of a post-operative inflammatory reaction and damage to the paravertebral muscles. Thirty-three patients who underwent lumbar discectomy or one-level unilateral laminotomy (MED in 15 cases, MD in 11 cases and one-level unilateral laminotomy in 7 cases with lumbar spinal canal stenosis) were included in this study. The serum levels of C-reactive protein (CRP) and creatine phosphokinase (CPK) were measured at 24 h after operation. Interleukin-6 (IL-6) and Interleukin-10 (IL-10) were measured at 2, 4, 8 and −24 h following the surgery to monitor the inflammatory response to the respective surgery. The post-operative serum CRP levels from both the MD and MED groups were significantly lower than those from the open laminotomy group. However, there was no significant difference in these serum levels between the MED and MD groups. The levels of IL-6 and IL-10 in the MED group during0 the first post-operative day were also significantly lower than those in the laminotomy group. When the MED and MD groups were compared, the IL-6 levels in the MED group were lower than in MD group at 2, 4 and 8 h after surgery, but the differences were not statistically significant. However, the level was significantly lower in the MED group at 24 h after surgery. In terms of IL-10, no significant difference was noted between the MED and MD groups over the study period. The changes in serum levels of post-operative inflammatory: markers (CRP, IL-6 and IL-10) in the early phase indicated reduced inflammatory reactions in MED as well as in MD when compared with classical open unilateral laminotomy. These data draw a direct link between the lower level of the inflammatory response and reduced invasiveness of MED. However, an indicator for muscle damage (CPK) appeared not to be affected by the type of surgical procedure used to correct disc herniation.
PMCID: PMC3489336  PMID: 15926058
Microendoscopic discectomy; Microdiscectomy; Lumbar disc herniation; Minimally invasive surgery
4.  Revisional Percutaneous Full Endoscopic Disc Surgery for Recurrent Herniation of Previous Open Lumbar Discectomy 
Asian Spine Journal  2011;5(1):1-9.
Study Design
A retrospective study.
To determine the feasibility and effectiveness of revisional percutaneous full endoscopic discectomy for recurrent herniation after conventional open disc surgery.
Overview of the Literature
Repeated open discectomy with or without fusion has been the most common procedure for recurrent lumbar disc herniation. Percutaneous endoscopic lumbar discectomy for recurrent herniation has been thought of as an impossible procedure. Despite good results with open revisional surgery, major problems may be caused by injuries to the posterior stabilized structures. Our team did revisional full endoscopic lumbar disc surgery on the basis of our experience doing primary full endoscopic disc surgery.
Between February 2004 and August 2009 a total of 41 patients in our hospital underwent revisional percutaneous endoscopic lumbar discectomy using a YESS endoscopic system and a micro-osteotome (designed by the authors). Indications for surgery were recurrent disc herniation following conventional open discectomy; with compression of the nerve root revealed by Gadolinium-enhanced magnetic resonance imaging; corresponding radiating pain which was not alleviated after conservative management over 6 weeks. Patients with severe neurologic deficits and isolated back pain were excluded.
The mean follow-up period was 16 months (range, 13 to 42 months). The visual analog scale for pain in the leg and back showed significant post-treatment improvement (p < 0.001). Based on a modified version of MacNab's criteria, 90.2% showed excellent or good outcomes. There was no measurable blood loss. There were two cases of recurrence of and four cases with complications.
Percutaneous full-endoscopic revisional disc surgery without additional structural damage is feasible and effective in terms of there being less chance of fusion and bleeding. This technique can be an alternative to conventional repeated discectomy.
PMCID: PMC3047892  PMID: 21386940
Endoscopic discectomy; Interlaminar discectomy; Transforaminal discectomy; Percutaneous discectomy; Recurrent disc herniation; Lumbar spine
5.  Clinical results of XMR-assisted percutaneous transforaminal endoscopic lumbar discectomy 
Although percutaneous endoscopic lumbar discectomy (PELD) has shown favorable outcomes in the majority of lumbar discectomy cases, there were also some failures. The most common cause of failure is the incomplete removal of disc fragments. The skin entry point for the guide-needle trajectory and the optimal placement of the working sleeve are largely blind, which might lead to the inadequate removal of disc fragments. The objective of this study was to present our early experiences with image-guided PELD using a specially designed fluoroscope with magnetic resonance imaging-equipped operative suite (XMR) for the treatment of lumbar disc herniation.
This prospective study included 89 patients who had undergone PELD via the transforaminal approach using an XMR protocol. Pre- and postoperative examinations (at 12 weeks) included a detailed clinical history, visual analogue scale (VAS), Oswestry disability index (ODI), and radiological workups. The results were categorized as excellent, good, fair, and poor according to MacNab's criteria. At the final follow-up, the minimum follow-up time for the subjects was 2 years. The need for revision surgeries and postoperative complications were noted on follow-up.
Postoperative mean ODI decreased from 67.4% to 5.61%. Mean VAS score for back and leg pain improved significantly from 4 to 2.3 and from 7.99 to 1.04, respectively. Four (4.49%) patients underwent a second-stage PELD after intraoperative XMR had shown remnant fragments after the first stage. As per MacNab's criteria, 76 patients (85.4%) showed excellent, 8 (8.89%) good, 3 (3.37%) fair, and 2 (2.25) poor results. Four (4.49%) patients had remnant disc fragments on XMR, which were removed during the same procedure. All of these patients had either highly migrated or sequestrated disc fragments preoperatively. Four (4.49%) other patients needed a second, open surgery due to symptomatic postoperative hematoma (n = 2) and recurrent disc herniation (n = 2).
This prospective analysis indicates that XMR-assisted PELD provides a precise skin entry point. It also confirms that decompression occurs intraoperatively, which negates the need for a separate surgery and thus increases the success rate of PELD, particularly in highly migrated or sequestrated discs. However, further extensive experience is required to confirm the advantages and feasibility of PELD in terms of cost effectiveness.
PMCID: PMC3668223  PMID: 23705685
Percutaneous endoscopic lumbar discectomy; Incomplete disc removal; XMR-guided procedure; High success rate
6.  Huge Psoas Muscle Hematoma due to Lumbar Segmental Vessel Injury Following Percutaneous Endoscopic Lumbar Discectomy 
We present a case of an acute psoas muscle hematoma following percutaneous endoscopic lumbar discectomy. A 60-year-old female who presented with far lateral lumbar disc herniation underwent endoscopic discectomy on the right side at the L4-5 level. On the second postoperative day, the patient complained of severe right flank and leg pain and her blood pressure decreased. A computed tomography scan showed a large acute psoas muscle hematoma at right L4-5 level. The patient was transfused with packed red blood cells and placed at absolute bed rest. After observing the patient in intensive care, the severe flank and leg pain subsided, but the mild back pain persisted. Although percutaneous endoscopic lumbar discectomy is an effective minimally invasive surgical technique for the treatment of lumbar disc herniation, this case highlights the inherent risks of acute lumbar segmental vessel injury.
PMCID: PMC2666125  PMID: 19352485
Percutaneous endoscopic lumbar discectomy; Psoas muscle hematoma; Lumbar segmental vessel injury
7.  Posterior endoscopic discectomy (and other procedures) 
European Spine Journal  2000;9(Suppl 1):S024-S029.
Percutaneous approaches to lumbar discectomy were somewhat controversial, because of their limited indications. They have not proven to be as effective as standard open lumbar disc surgery, because of longer operating times and some technical problems in addressing all the different aspects of lumbar disc herniations. New percutaneous posterior procedures for lumbar disc disease have been described in the last few years, but the MicroEndoscopic Discectomy (MED) introduced by Foley and Smith in 1997 seems to be the most promising one. MED, and METR’x which evolved from it, . allow the surgeon to address not only contained lumbar disc herniations, but also free-fragment disc pathology and symptomatic lateral recess stenosis secondary to bony hypertrophy. The surgical technique is summarized and some preliminary clinical results of a prospective multicenter study with 13 months’ mean follow-up are presented.
PMCID: PMC3611440
Key words Disc herniation; Posterior approach; Microdiscectomy; Endoscopic ¶approach
8.  Recurrent lumbar disc herniation: A prospective comparative study of three surgical management procedures 
Asian Journal of Neurosurgery  2013;8(3):139-146.
The optimal surgical treatment of recurrent lumbar disc herniation is controversial.
To compare prospectively the clinical outcomes of surgical treatment of recurrent lumbar disc herniation by three different methods; discectomy alone, discectomy with transforaminal lumbar interbody fusion (TLIF), and diecectomy with posterolateral fusion (PLF), regardless of the postoperative radiological findings.
Study Design:
This is a prospective, randomized, comparative study.
Materials and Methods:
This is a prospective, randomized, comparative study on 45 patients with first time recurrent lumbar disc herniation. Patients were evaluated clinically by using the criteria of the Japanese Orthopedic Association's evaluation system for low back pain syndrome (JOA score). The patients were classified into three groups: Group A; patients who had revision discectomy alone, group B; patients who had revision discectomy with TLIF, and group C; patients who had revision discectomy with PLF. The mean follow-up period was 37 (±7.85 STD) months.
The mean overall recovery rate was 87.2% (±19.26 STD) and the satisfactory rate was 88.9%. Comparison between the three groups showed no significant difference with regard to the mean total postoperative JOA score, recovery rate, and satisfactory rate. However, the postoperative low back pain was significantly higher in group A than that of group B and C. Two patients in group A required further revision surgery. The incidences of dural tear and postoperative neurological deficit were higher in group A. The intraoperative blood loss and length of operation were significantly less in group A. The total cost of the procedure was significantly different between the three groups, being least in group A and highest in group B. There was no significant difference between the three groups with regard to the length of postoperative hospital stay.
Revision discectomy is effective in patients with recurrent lumbar disc herniation. Fusion with revision discectomy improves the postoperative low back pain, decreases the intraoperative risk of dural tear or neural damage and decreases the postoperative incidence of mechanical instability or re-recurrence. TLIF and PLF have comparable results when used with revision discectomy, but PLF has significantly less total cost than TLIF.
PMCID: PMC3877500  PMID: 24403956
Anterior lumbar interbody fusion; posterior lumbar interbody fusion; posterolateral fusion; recurrent lumbar disc herniation; transforaminal lumbar interbody fusion
9.  Cost-effectiveness of microendoscopic discectomy versus conventional open discectomy in the treatment of lumbar disc herniation: a prospective randomised controlled trial [ISRCTN51857546] 
Open discectomy is the standard surgical procedure in the treatment of patients with long-lasting sciatica caused by lumbar disc herniation. Minimally invasive approaches such as microendoscopic discectomy have gained attention in recent years. Reduced tissue trauma allows early ambulation, short hospital stay and quick resumption of daily activities. A comparative cost-effectiveness study has not been performed yet. We present the design of a randomised controlled trial on cost-effectiveness of microendoscopic discectomy versus conventional open discectomy in patients with lumbar disc herniation.
Patients (age 18–70 years) presenting with sciatica due to lumbar disc herniation lasting more than 6–8 weeks are included. Patients with disc herniation larger than 1/3 of the spinal canal diameter, or disc herniation less than 1/3 of the spinal canal diameter with concomitant lateral recess stenosis or sequestration, are eliglible for participation. Randomisation into microendoscopic discectomy or conventional unilateral transflaval discectomy will take place in the operating room after induction of anesthesia. The length of skin incision is equal in both groups. The primary outcome measure is the functional assessment of the patient, measured by the Roland Disability Questionnaire for Sciatica, at 8 weeks and 1 year after surgery. We will also evaluate several other outcome parameters, including perceived recovery, leg and back pain, incidence of re-operations, complications, serum creatine kinase, quality of life, medical consumption, absenteeism and costs. The study is a randomised prospective multi-institutional trial, in which two surgical techniques are compared in a parallel group design. Patients and research nurses are kept blinded of the allocated treatment during the follow-up period of 2 years.
Currently, open discectomy is the golden standard in the surgical treatment of lumbar disc herniation. Whether microendoscopic discectomy is more cost-effective than unilateral transflaval discectomy has to be determined by this trial.
PMCID: PMC1475863  PMID: 16696861
10.  Microendoscopic lumbar discectomy versus open surgery: an intraoperative EMG study 
European Spine Journal  2001;11(1):20-26.
This study investigated electromyographic (EMG) activity as a marker of nerve root irritation during two different surgical procedures for lumbar disc herniation. Mechanically elicited EMG activity was recorded during the dynamic stages of surgery in muscle groups innervated by lumbar nerve roots. Confirmation of surgical activity was correlated with the activity of the electromyogram. Fifteen patients with lumbar disc herniations were treated via an endoscopic medial approach, and 15 patients via the open microscopic surgical technique. Results indicated that the endoscopic technique was superior to the open surgical technique and produced less irritation of the nerve root. Significantly less mechanically elicited activity was recorded during both the approach and the root mobilization. The study showed that microendoscopic discectomy allows a smaller incision and less tissue trauma with comparable visualization of the nerve structures than does open surgery.
PMCID: PMC3610497  PMID: 11931060
Microendoscopic discectomy Intraoperative EMG Lumbar disc herniation
11.  Percutaneous endoscopic lumbar discectomy: clinical and quality of life outcomes with a minimum 2 year follow-up 
Percutaneous endoscopic lumbar discectomy is a relatively new technique. Very few studies have reported the clinical outcome of percutaneous endoscopic discectomy in terms of quality of life and return to work.
55 patients with percutaneous endoscopic lumbar discectomy done from 2002 to 2006 had their clinical outcomes reviewed in terms of the North American Spine Score (NASS), Medical Outcomes Study Short Form-36 scores (SF-36) and Pain Visual Analogue Scale (VAS) and return to work.
The mean age was 35.6 years, the mean operative time was 55.8 minutes and the mean length of follow-up was 3.4 years. The mean hospital stay for endoscopic discectomy was 17.3 hours. There was significant reduction in the severity of back pain and lower limb symptoms (NASS and VAS, p < 0.05) at 6 months and 2 years. There was significant improvement in all aspects of the Quality of Life (SF-36, p < 0.05) scores except for general health at 6 months and 2 years postoperation. The recurrence rate was 5% (3 patients). 5% (3 patients) subsequently underwent lumbar fusion for persistent back pain. All patients returned to their previous occupation after surgery at a mean time of 24.3 days.
Percutaneous endoscopic lumbar discectomy is associated with improvement in back pain and lower limb symptoms postoperation which translates to improvement in quality of life. It has the advantage that it can be performed on a day case basis with short length of hospitalization and early return to work thus improving quality of life earlier.
PMCID: PMC2712454  PMID: 19555483
12.  Treatment of multilevel degenerative lumbar spinal stenosis with spondylolisthesis using a combination of microendoscopic discectomy and minimally invasive transforaminal lumbar interbody fusion 
Degenerative lumbar spinal stenosis (DLSS) has become increasingly common and is characterized by multilevel disc herniation and lumbar spondylolisthesis, which are difficult to treat. The current study aimed to evaluate the short-term clinical outcomes and value of the combined use of microendoscopic discectomy (MED) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for the treatment of multilevel DLSS with spondylolisthesis, and to compare the combination with traditional posterior lumbar interbody fusion (PLIF). A total of 26 patients with multilevel DLSS and spondylolisthesis underwent combined MED and MI-TLIF surgery using a single cage and pedicle rod-screw system. These cases were compared with 27 patients who underwent traditional PLIF surgery during the same period. Data concerning incision length, surgery time, blood loss, time of bed rest and Oswestry Disability Index (ODI) score prior to and following surgery were analyzed statistically. Statistical significance was reached in terms of incision length, blood loss and the time of bed rest following surgery (P<0.05), but there was no significant difference between the surgery time and ODI scores of the two groups. The combined use of MED and MI-TLIF has the advantages of reduced blood loss, less damage to the paraspinal soft tissue, shorter length of incision, shorter bed rest time, improved outcomes and shorter recovery times and has similar short-term clinical outcomes to traditional PLIF.
PMCID: PMC3570089  PMID: 23403827
microendoscopic discectomy; minimally invasive transforaminal lumbar interbody fusion; posterior lumbar interbody fusion; lumbar spinal stenosis; lumbar spondylolisthesis
13.  Treatment outcomes of 130 patients underwent an endoscopic discectomy 
Journal of Injury and Violence Research  2012;4(3 Suppl 1): Paper No. 34.
Endoscopic discectomy method is a novel technique that is increasingly used in spine surgery. Previous studies have reported that some common complications like dural adhesions are lower in this technique compared with the other techniques. Furthermore, treatment outcomes are reportedly higher because of minimal invasion. Thepresent study aims to determine the outcome of percutaneous endoscopic discectomy.
A total of 130 patients underwent the lumbar disc prolapse operations during 2008 to 2012 in all of them the entire procedure was performed endoscopically. All procedures were carried out from a posterior approach using a 4-mm Hopkins 0 degrees-telescope placed in the working insert equipped with channels for suction tube, operative instruments and nerve root retractor (ENDOSPINE instrumentation (Karl STORZ GmbH and Co. KG). The pre- and post-operation pain was assessed using a Visual Analog Scale (VAS). Furthermore, the treatment outcome was assessed using modified MacNab criteria before operation, 24 hours, one month, 2 months, 6 months, one year, and two years after operation .
Good to excellent outcome was achieved in 89% of patients, which is comparable with the results of classic microdiscectomy. The mean age of patients was 35.6 years old and the mean length of follow-up was 3.4 years. There was significant reduction in the severity of back pain and lower limb symptoms at 6 months and 2 years post-operation. There was significant improvement in all aspects of the Quality of Life scores at 6 months and 2 years post-operation. In 3 patients the dural sac was lacerated but none of the tears was exceed a few mm in length with not association with neural injury.
Findings of this study showed that percutaneous endoscopic lumbar discectomy is associated with improvement in back pain and lower limb symptoms. It has the advantage that it can be performed on a day case basis with short length of hospitalization and early return to work thus improving quality of life earlier.
Endoscopic discectomy, Spine surgery, Lumbar disc prolapse operation, Outcome
PMCID: PMC3571560
14.  Posterior endoscopic discectomy: Results in 300 patients 
Indian Journal of Orthopaedics  2012;46(1):81-85.
Posterior endoscopic discectomy is an established method for treatment of lumbar disc herniation. Many studies have not been reported in literature for lumbar discectomy by Destandau Endospine System. We report a series of 300 patients operated for lumbar dissectomy by Destandau Endospine system.
Materials and Methods:
A total of 300 patients suffering from lumbar disc herniations were operated between January 2002 and December 2008. All patients were operated as day care procedure. Technique comprised localization of symptomatic level followed by insertion of an endospine system devise through a 15 mm skin and fascial incision. Endoscopic discectomy is then carried out by conventional micro disc surgery instruments by minimal invasive route. The results were evaluated by Macnab's criteria after a minimum followup of 12 months and maximum up to 24 months.
Based on modified Macnab's criteria, 90% patients had excellent to good, 8% had fair, and 2% had poor results. The complications observed were discitis and dural tear in five patients each and nerve root injury in two patients. 90% patients were able to return to light and sedentary work with an average delay of 3 weeks and normal physical activities after 2 months.
Edoscopic discectomy provides a safe and minimal access corridor for lumbar discectomy. The technique also allows early postoperative mobilization and faster return to work.
PMCID: PMC3270611  PMID: 22345812
Endoscope; endoscopic discectomy; endospine; facetectomy; laminotomy; radiculopathy
15.  Comparison of Percutaneous Endoscopic Lumbar Discectomy and Open Lumbar Microdiscectomy for Recurrent Disc Herniation 
The purpose of this study was to compare clinical and radiological outcomes of percutaneous endoscopic lumbar discectomy (PELD) and open lumbar microdiscectomy (OLM) for recurrent disc herniation.
Fifty-four patients, who underwent surgery, either PELD (25 patients) or repeated OLM (29 patients), due to recurrent disc herniation at L4-5 level, were divided into two groups according to the surgical methods. Excluded were patients with sequestrated disc, calcified disc, severe neurological deficit, or instability. Clinical outcomes were assessed using Visual Analogue Scale (VAS) score and Oswestry Disability Index (ODI). Radiological variables were assessed using plain radiography and/or magnetic resonance imaging.
Mean operating time and hospital stay were significantly shorter in PELD group (45.8 minutes and 0.9 day, respectively) than OLM group (73.8 minutes and 3.8 days, respectively) (p < 0.001). Complications occurred in 4% in PELD group and 10.3% in OLM group in the perioperative period. At a mean follow-up duration of 34.2 months, the mean improvements of back pain, leg pain, and functional improvement were 4.0, 5.5, and 40.9% for PELD group and 2.3, 5.1, and 45.0% for OLM group, respectively. Second recurrence occurred in 4% after PELD and 10.3% after OLM. Disc height did not change after PELD, but significantly decreased after OLM (p = 0.0001). Neither sagittal rotation angle nor volume of multifidus muscle changed significantly in both groups.
Both PELD and repeated OLM showed favorable outcomes for recurrent disc herniation, but PELD had advantages in terms of shorter operating time, hospital stay, and disc height preservation.
PMCID: PMC2803265  PMID: 20062565
Reherniation; Discectomy; Lumbar spine
16.  Clinical and radiological instability following standard fenestration discectomy 
Indian Journal of Orthopaedics  2009;43(4):347-351.
Post-surgical lumbar instability is an established complication but there is limited evidence in the literature regarding the incidence of lumbar instability following fenestration and discectomy. We analyzed our results following fenestration discectomy with a special focus on instability.
Materials and Methods:
Eighty-three patients between the age of 17 and 52 years who had undergone fenestration discectomy for a single-level lumbar intervertebral disc prolapse were followed-up for a period of 1–5 years. The criteria for instability included “instability catch,”, “painful catch,” and “apprehension.” The working capacity of the patient and the outcome score of the surgery were assessed by means of the Oswestry disability score and the Prolo economic and functional outcome score. Flexion-extension lateral radiographs were taken and analyzed for abnormal tilt and translation.
Of the 83 patients included, 70 were men and 13 were women, with an average age of 37.35 years (17–52 years) at 5 years follow-up. Clinical instability was seen in 10 (12.04%) patients. Radiological instability was noted in 29 (34.9%) patients. Only six (60%) of the 10 patients who demonstrated clinical instability had radiological evidence of instability. Twenty (68.96%) patients with radiological instability were asymptomatic. Three (10.34%) patients with only radiological instability had unsatisfactory outcome. The Oswestry scoring showed an average score of 19.8%. Mild disability was noted in 59 (71.08%) patients and moderate disability was seen in 24 (28.91%) patients. None of the patients had severe disability. These outcomes were compared with the outcomes in other studies in the literature for microdiscectomy and the results were found to be comparable.
The favorable outcome of this study is in good agreement with other studies on microdiscectomy. Clinical instability in 12.04% of the patients is in agreement with other studies. Radiological signs of instability are seen even in asymptomatic patients and so are not as reliable as clinical signs of instability. Standard fenestration discectomy does not destabilize the spine more than microdiscectomy.
PMCID: PMC2762566  PMID: 19838384
Discectomy; fenestration; instability
17.  Minimally invasive discectomy versus microdiscectomy/ discectomy for symptomatic lumbar disc herniation 
Journal of Injury and Violence Research  2012;4(3 Suppl 1): Paper No. 61.
Lumbar discectomy is a surgery to remove all or part of a disc cushion that helps protect the spinal column. These cushions, called disks, separate the spinal vertebrae/bones. When one of the disks herniates (moves out of place) in patients with protruded disc, the soft gel inside pushes through the wall of the disk. The disk may then place pressure on the spinal cord and nerves that are coming out of the spinal column.
The lumbar discectomy procedure remained basically unchanged until the operating microscope enhanced the visualization of the operative field in 1978. This new operation was recognized as lumbar microdiscectomy because it was performed through a smaller incision, with less dissection than standard open lumbar discectomy. Microdiscectomy is regarded generally as a technical modification of standard discectomy, rather than a separate procedure. In a systematic review by Gibson and Waddell, results of microdiscectomy for treatment of lumbar disc prolapse was “broadly comparable” to the standard open lumbar discectomy. (Conventional microdiscectomy is now considered common surgical treatment for lumbar disc herniation).
Several minimally invasive surgical approaches have been introduced for the surgical management of symptomatic lumbar disc herniation. The effectiveness of these procedures should be compared with lumbar microdiscectomy. Systematic reviews comparing specific types of minimally invasive lumbar surgery for management of lumbar disc herniation and lumbar radiculopathy, but did not yield conclusive results due to a lack of evidence. In this paper, we perform a systematic review of the literature and draw conclusions about safety and efficacy of minimally invasive discectomy compared to standard microdiscectomy.
Minimally invasive discectomy, Microdiscectomy, Disk herniation
PMCID: PMC3571587
18.  MSU Classification for herniated lumbar discs on MRI: toward developing objective criteria for surgical selection 
European Spine Journal  2010;19(7):1087-1093.
Currently, there are over 300,000 lumbar discectomies performed in the US annually without an objective standard for patient selection. A prospective clinical outcome study of 200 cases with 5-year follow-up was used to develop and validate an MRI-based classification scheme to eliminate as much ambiguity as possible. 100 consecutive lumbar microdiscectomies were performed between 1992 and 1995 based on the criteria for “substantial” herniation on MRI. This series was used to develop the MSU Classification as an objective measure of lumbar disc herniation on MRI to define “substantial”. It simply classifies herniation size as 1-2-3 and location as A-B-C, with inter-examiner reliability of 98%. A second prospective series of 100 discectomies was performed between 2000 and 2002, based on the new criteria, to validate this classification scheme. All patients with size-1 lesions were electively excluded from surgical consideration in our study. The Oswestry Disability Index from both series was better than most published outcome norms for lumbar microdiscectomy. The two series reported 96 and 90% good to excellent outcomes, respectively, at 1 year, and 84 and 80% at 5 years. The most frequent types of herniation selected for surgery in each series were types 2-B and 2-AB, suggesting the combined importance of both size and location. The MSU Classification is a simple and reliable method to objectively measure herniated lumbar disc. When used in correlation with appropriate clinical findings, the MSU Classification can provide objective criteria for surgery that may lead to a higher percentage of good to excellent outcomes.
PMCID: PMC2900017  PMID: 20084410
MRI; Discectomy; Classification; Substantial herniated disc; Low back pain
19.  Primary and revision lumbar discectomy: A three-year review from one center 
Indian Journal of Orthopaedics  2008;42(2):178-181.
Despite variations in technique, the results of primary and revision lumbar discectomy have been good. The aim of this study was to retrospectively review cases of primary and revision lumbar discectomy performed in our institute over a three-year period.
Materials and Methods:
The case records of 273 patients who underwent lumbar discectomy between January 2001-2004 and fulfilled our inclusion and exclusion criteria were reviewed. Of these, 259 were primary discectomies and 14 were revision surgeries. Recurrence was defined as ipsilateral disc herniation at the previously operated level. Demographic parameters, magnetic resonance imaging of the disc, patient satisfaction and rate of recurrence were analyzed.
The primary surgery group had 52 (20.08%) contained and 207 (79.92%) extruded or sequestered discs, while the numbers in the revision group were three (21.43%) and 11 (78.57%) respectively. “Satisfactory” outcome was noted in 96.5% of the primary surgeries, with a recurrence rate of 3.5%. In the revision group 78.6% had “satisfactory” outcome. In 9.4% of the primary group we encountered complications, while it was 21.43% in the revision group.
Lumbar discectomy is a safe, simple and effective procedure with satisfactory outcome in 96.5% of primary disc surgery and 78.6% of revision disc surgery.
PMCID: PMC2759631  PMID: 19826524
Lumbar discectomy; herniated disc; revision discectomy
20.  Computed tomographic analysis of the quality of trunk muscles in asymptomatic and symptomatic lumbar discectomy patients 
No consensus exists on how rehabilitation programs for lumbar discectomy patients with persistent complaints after surgery should be composed. A better understanding of normal and abnormal postoperative trunk muscle condition might help direct the treatment goals.
A three-dimensional CT scan of the lumbar spine was obtained in 18 symptomatic and 18 asymptomatic patients who had undergone a lumbar discectomy 42 months to 83 months (median 63 months) previously. The psoas muscle (PS), the paraspinal muscle mass (PA) and the multifidus muscle (MF) were outlined at the L3, L4 and L5 level. Of these muscles, fat free Cross Sectional Area (CSA) and fat CSA were determined. CSA of the lumbar erector spinae (LES = longissimus thoracis + iliocostalis lumborum) was calculated by subtracting MF CSA from PA CSA. Mean muscle CSA of the left and right sides was calculated at each level. To normalize the data for interpersonal comparison, the mean CSA was divided by the CSA of the L3 vertebral body (mCSA = normalized fat-free muscle CSA; fCSA = normalized fat CSA). Differences in CSA between the pain group and the pain free group were examined using a General Linear Model (GLM). Three levels were examined to investigate the possible role of the level of operation.
In lumbar discectomy patients with pain, the mCSA of the MF was significantly smaller than in pain-free subjects (p = 0.009) independently of the level. The mCSA of the LES was significantly smaller in pain patients, but only on the L3 slice (p = 0.018). No significant difference in mCSA of the PS was found between pain patients and pain-free patients (p = 0.462). The fCSA of the MF (p = 0.186) and of the LES (p = 0.256) were not significantly different between both populations. However, the fCSA of the PS was significantly larger in pain patients than in pain-free patients. (p = 0.012).
The level of operation was never a significant factor.
CT comparison of MF, LES and PS muscle condition between lumbar discectomy patients without pain and patients with protracted postoperative pain showed a smaller fat-free muscle CSA of the MF at all levels examined, a smaller fat- free muscle CSA of the LES at the L3 level, and more fat in the PS in patients with pain. The level of operation was not found to be of importance. The present results suggest a general lumbar muscle dysfunction in the pain group, in particular of the deep stabilizing muscle system.
PMCID: PMC3079706  PMID: 21453531
21.  Comparison of outcomes between conventional lumbar fenestration discectomy and minimally invasive lumbar discectomy: an observational study with a minimum 2-year follow-up 
Different surgical techniques for lumbar discectomy are in vogue. This study compares the outcomes of two techniques for lumbar discectomy, viz. micro lumbar discectomy (LD) and conventional fenestration discectomy.
Materials and methods
Sixty-six patients who had single-level 'virgin’ lumbar disc herniation with unilateral radicular symptoms were included. Of these, 39 had undergone MLD while 27 had undergone fenestration. Outcomes were measured using the visual analogue scale (VAS) for back and leg pain, Japanese Orthopedic Association (JOA) score, Roland-Morris score (RM) improvement and North American Spine Society (NASS) score. All quantitative data were summarised using mean and standard deviation, and qualitative data using proportions. Significance of differences across the two groups in terms of mean scores was assessed using independent sample t test, and the improvement within the same groups was measured using paired t test. Multiple linear regression analysis was done to assess independent predictors of improvement.
The MLD group showed statistically better outcomes with regard to improvement in JOA score at 6 weeks, 6 months and 2 years. Mean (SD) VAS for lower back ache at 6 weeks, 6 months, and 2 years was better for the MLD group. But the difference noted in VAS for leg pain was not statistically significant across the groups (P = 0.133). The improvement noted in JOA at 2 years postoperatively compared to the preoperative score was 13.67 (2.89) in the MLD group and 12.11 (3.30) in the macrodiscectomy group (P = 0.046).
The mean (SD) RM improvement for the MLD group was 79.24% (8.96%) vs 71.72% (16.53), P = 0.02, in the macrodiscectomy group. Mean NASS score for the MLD group was 2.74 vs 2.96 in the conventional group (P = 0.407).
The type of surgery was the significant predictor of improvement in JOA score (P = 0.046) even after adjusting for age, sex, level of lesion and the initial JOA score. MLD as the surgical procedure (P = 0.002) and a lower initial JOA score (P = 0.006) were found significantly contributing to the RM improvement.
The study shows that both MLD and fenestration give comparable results at short-term follow-up. There is statistically significant improvement in MLD with regard to improvement in JOA, VAS and RM scores at 2 years. However, the difference is not large and may not be clinically significant.
PMCID: PMC3849663  PMID: 24063775
Fenestration discectomy; Minimally invasive lumbar discectomy; MLD
22.  Endoscopic decompression for intraforaminal and extraforaminal nerve root compression 
The purpose of this study was to evaluate the outcome of endoscopic decompression surgery for intraforaminal and extraforaminal nerve root compression in the lumbar spine.
The records from seventeen consecutive patients treated with endoscopic posterior decompression without fusion for intaforaminal and extraforaminal nerve root compression in the lumbar spine (7 males and 10 females, mean age: 67.9 ± 10.7 years) were retrospectively reviewed. The surgical procedures consisted of lateral or translaminal decompression with or without discectomy. The following items were investigated: 1) the preoperative clinical findings; 2) the radiologic findings including MRI and computed tomography-discography; and 3) the surgical outcome as evaluated using the Japanese Orthopaedic Association scale for lower back pain (JOA score).
All patients had neurological findings compatible with a radiculopathy, such as muscle weakness and sensory disturbance. MRI demonstrated the obliteration of the normal increased signal intensity fat in the intervertebral foramen. Ten patients out of 14 who underwent computed tomography-discography exhibited disc protrusion or herniation. Selective nerve root block was effective in all patients. During surgery, 12 patients were found to have a protruded disc or herniation that compressed the nerve root. Sixteen patients reported pain relief immediately after surgery.
Intraforaminal and extraforaminal nerve root compression is a rare but distinct pathological condition causing severe radiculopathy. Endoscopic decompression surgery is considered to be an appropriate and less invasive surgical option.
PMCID: PMC3073935  PMID: 21439083
23.  Translaminar Microendoscopic Herniotomy for Cranially Migrated Lumbar Disc Herniations Encroaching on the Exiting Nerve Root in the Preforaminal and Foraminal Zones 
Asian Spine Journal  2013;7(3):190-195.
Study Design
Case series.
The aim of this study was to describe translaminar microendoscopic herniotomy (TL-MEH) for cranially migrated lumbar disc herniations encroaching on the exiting nerve root in the preforaminal and foraminal zones and to report preliminary results of the procedure.
Overview of Literature
Conventional interlaminar approaches for preforaminal and foraminal lumbar disc herniations result in extensive removal of the lamina and facet joint to remove disc fragments safely. More destructive approaches increase the risk of postoperative segmental instability.
TL-MEH is a minimally invasive procedure for herniotomy via the translaminar approach using a microendoscopic technique. TL-MEH was performed in seven patients with a cranially migrated lumbar disc herniation encroaching on the exiting nerve root. The disc fragments were located in the preforaminal zone in four patients, and in the preforaminal and foraminal zones in three.
All patients experienced immediate relief from symptoms after surgery and satisfactory results at the final follow-up. Surgical complications, such as a dural tear, nerve injury, and surgical site infection, were not investigated.
TL-MEH seemed to be an effective and safe alternative minimally invasive surgical option for patients with a cranially migrated lumbar disc herniation encroaching the exiting nerve root in the preforaminal and foraminal zones.
PMCID: PMC3779770  PMID: 24066214
Lumbar disc herniation; Endoscopic surgery; Translaminar approach; Tubular surgery
24.  Higher risk of dural tears and recurrent herniation with lumbar micro-endoscopic discectomy 
European Spine Journal  2010;19(3):443-450.
Existing studies on micro-endoscopic lumbar discectomy report similar outcomes to those of open and microdiscectomy and conflicting results on complications. We designed a randomised controlled trial to investigate the hypothesis of different outcomes and complications obtainable with the three techniques. 240 patients aged 18–65 years affected by posterior lumbar disc herniation and symptoms lasting over 6 weeks of conservative management were randomised to micro-endoscopic (group 1), micro (group 2) or open (group 3) discectomy. Exclusion criteria were less than 6 weeks of pain duration, cauda equina compromise, foraminal or extra-foraminal herniations, spinal stenosis, malignancy, previous spinal surgery, spinal deformity, concurrent infection and rheumatic disease. Surgery and follow-up were made at a single Institution. A biomedical researcher independently collected and reviewed the data. ODI, back and leg VAS and SF-36 were the outcome measures used preoperatively, postoperatively and at 6-, 12- and 24-month follow-up. 212/240 (91%) patients completed the 24-month follow-up period. VAS back and leg, ODI and SF36 scores showed clinically and statistically significant improvements within groups without significant difference among groups throughout follow-up. Dural tears, root injuries and recurrent herniations were significantly more common in group 1. Wound infections were similar in group 2 and 3, but did not affect patients in group 1. Overall costs were significantly higher in group 1 and lower in group 3. In conclusion, outcome measures are equivalent 2 years following lumbar discectomy with micro-endoscopy, microscopy or open technique, but severe complications are more likely and costs higher with micro-endoscopy.
PMCID: PMC2899770  PMID: 20127495
Lumbar disc herniation; Discectomy; Microdiscectomy; Micro-endoscopic discectomy
25.  Frequency and clinical meaning of long-term degenerative changes after lumbar discectomy visualized on imaging tests 
European Spine Journal  2009;19(1):136-143.
The aim of this retrospective controlled study was to evaluate radiographic degeneration in the lumbar spine of patients who had undergone lumbar discectomy minimum 21 years earlier and its clinical meaning. Indeed, no previous investigation on degenerative changes occurring after lumbar discectomy with a comparable long follow-up has been published. The study participants consisted of 50 patients who had undergone discectomy for lumbar disc herniation. The mean length of follow-up was 25.3 ± 3.0 years. Patients were assessed by Short Form-36 Health Survey (SF-36), Oswestry Disability Index, and a study-specific questionnaire. Radiographic views of the lumbar spine were obtained from all patients and compared to those of 50 asymptomatic controls. A five-step published classification was used to assess the increasing severity of radiographic changes. CT or MRI scans were also available for 27 patients who had undergone discectomy. Moderate to severe radiographic changes were present in 45 patients (90%) and 34 controls (68%), respectively (P = 0.013). The most prevalent MRI/CT changes were loss of disc height (89%), facet joint arthritis (89%), and endplate changes (57%). Thirty-two of 33 subjects (97%) reporting pain during the last 12 months had significant degeneration on their radiographs, and the frequency of changes was higher with respect to subjects without pain (P = 0.040). In conclusion, standard lumbar discectomy frequently leads to long-term degenerative changes on imaging tests. The presence of moderate to severe degeneration is associated with self-reported pain.
PMCID: PMC2899737  PMID: 19894068
Discectomy; Low back pain; Long term follow-up; Lumbar spine; Radiography; Surgery

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