Search tips
Search criteria

Results 1-25 (992775)

Clipboard (0)

Related Articles

1.  Minimally invasive surgical procedures for the treatment of lumbar disc herniation 
In up to 30% of patients undergoing lumbar disc surgery for herniated or protruded discs outcomes are judged unfavourable. Over the last decades this problem has stimulated the development of a number of minimally-invasive operative procedures. The aim is to relieve pressure from compromised nerve roots by mechanically removing, dissolving or evaporating disc material while leaving bony structures and surrounding tissues as intact as possible. In Germany, there is hardly any utilisation data for these new procedures – data files from the statutory health insurances demonstrate that about 5% of all lumbar disc surgeries are performed using minimally-invasive techniques. Their real proportion is thought to be much higher because many procedures are offered by private hospitals and surgeries and are paid by private health insurers or patients themselves. So far no comprehensive assessment comparing efficacy, safety, effectiveness and cost-effectiveness of minimally-invasive lumbar disc surgery to standard procedures (microdiscectomy, open discectomy) which could serve as a basis for coverage decisions, has been published in Germany.
Against this background the aim of the following assessment is:
Based on published scientific literature assess safety, efficacy and effectiveness of minimally-invasive lumbar disc surgery compared to standard procedures. To identify and critically appraise studies comparing costs and cost-effectiveness of minimally-invasive procedures to that of standard procedures. If necessary identify research and evaluation needs and point out regulative needs within the German health care system. The assessment focusses on procedures that are used in elective lumbar disc surgery as alternative treatment options to microdiscectomy or open discectomy. Chemonucleolysis, percutaneous manual discectomy, automated percutaneous lumbar discectomy, laserdiscectomy and endoscopic procedures accessing the disc by a posterolateral or posterior approach are included.
In order to assess safety, efficacy and effectiveness of minimally-invasive procedures as well as their economic implications systematic reviews of the literature are performed. A comprehensive search strategy is composed to search 23 electronic databases, among them MEDLINE, EMBASE and the Cochrane Library. Methodological quality of systematic reviews, HTA reports and primary research is assessed using checklists of the German Scientific Working Group for Health Technology Assessment. Quality and transparency of cost analyses are documented using the quality and transparency catalogues of the working group. Study results are summarised in a qualitative manner. Due to the limited number and the low methodological quality of the studies it is not possible to conduct metaanalyses. In addition to the results of controlled trials results of recent case series are introduced and discussed.
The evidence-base to assess safety, efficacy and effectiveness of minimally-invasive lumbar disc surgery procedures is rather limited:
Percutaneous manual discectomy: Six case series (four after 1998)Automated percutaneous lumbar discectomy: Two RCT (one discontinued), twelve case series (one after 1998)Chemonucleolysis: Five RCT, five non-randomised controlled trials, eleven case seriesPercutaneous laserdiscectomy: One non-randomised controlled trial, 13 case series (eight after 1998)Endoscopic procedures: Three RCT, 21 case series (17 after 1998)
There are two economic analyses each retrieved for chemonucleolysis and automated percutaneous discectomy as well as one cost-minimisation analysis comparing costs of an endoscopic procedure to costs for open discectomy.
Among all minimally-invasive procedures chemonucleolysis is the only of which efficacy may be judged on the basis of results from high quality randomised controlled trials (RCT). Study results suggest that the procedure maybe (cost)effectively used as an intermediate therapeutical option between conservative and operative management of small lumbar disc herniations or protrusions causing sciatica. Two RCT comparing transforaminal endoscopic procedures with microdiscectomy in patients with sciatica and small non-sequestered disc herniations show comparable short and medium term overall success rates. Concerning speed of recovery and return to work a trend towards more favourable results for the endoscopic procedures is noted. It is doubtful though, whether these results from the eleven and five years old studies are still valid for the more advanced procedures used today. The only RCT comparing the results of automated percutaneous lumbar discectomy to those of microdiscectomy showed clearly superior results of microdiscectomy. Furthermore, success rates of automated percutaneous lumbar discectomy reported in the RCT (29%) differ extremely from success rates reported in case series (between 56% and 92%).
The literature search retrieves no controlled trials to assess efficacy and/or effectiveness of laser-discectomy, percutaneous manual discectomy or endoscopic procedures using a posterior approach in comparison to the standard procedures. Results from recent case series permit no assessment of efficacy, especially not in comparison to standard procedures. Due to highly selected patients, modi-fications of operative procedures, highly specialised surgical units and poorly standardised outcome assessment results of case series are highly variable, their generalisability is low.
The results of the five economical analyses are, due to conceptual and methodological problems, of no value for decision-making in the context of the German health care system.
Aside from low methodological study quality three conceptual problems complicate the interpretation of results.
Continuous further development of technologies leads to a diversity of procedures in use which prohibits generalisation of study results. However, diversity is noted not only for minimally-invasive procedures but also for the standard techniques against which the new developments are to be compared. The second problem refers to the heterogeneity of study populations. For most studies one common inclusion criterion was "persisting sciatica after a course of conservative treatment of variable duration". Differences among study populations are noted concerning results of imaging studies. Even within every group of minimally-invasive procedure, studies define their own in- and exclusion criteria which differ concerning degree of dislocation and sequestration of disc material. There is the non-standardised assessment of outcomes which are performed postoperatively after variable periods of time. Most studies report results in a dichotomous way as success or failure while the classification of a result is performed using a variety of different assessment instruments or procedures. Very often the global subjective judgement of results by patients or surgeons is reported. There are no scientific discussions whether these judgements are generalisable or comparable, especially among studies that are conducted under differing socio-cultural conditions. Taking into account the weak evidence-base for efficacy and effectiveness of minimally-invasive procedures it is not surprising that so far there are no dependable economic analyses.
Conclusions that can be drawn from the results of the present assessment refer in detail to the specified minimally-invasive procedures of lumbar disc surgery but they may also be considered exemplary for other fields where optimisation of results is attempted by technological development and widening of indications (e.g. total hip replacement).
Compared to standard technologies (open discectomy, microdiscectomy) and with the exception of chemonucleolysis, the developmental status of all other minimally-invasive procedures assessed must be termed experimental. To date there is no dependable evidence-base to recommend their use in routine clinical practice. To create such a dependable evidence-base further research in two directions is needed: a) The studies need to include adequate patient populations, use realistic controls (e.g. standard operative procedures or continued conservative care) and use standardised measurements of meaningful outcomes after adequate periods of time. b) Studies that are able to report effectiveness of the procedures under everyday practice conditions and furthermore have the potential to detect rare adverse effects are needed. In Sweden this type of data is yielded by national quality registries. On the one hand their data are used for quality improvement measures and on the other hand they allow comprehensive scientific evaluations. Since the year of 2000 a continuous rise in utilisation of minimally-invasive lumbar disc surgery is observed among statutory health insurers. Examples from other areas of innovative surgical technologies (e.g. robot assisted total hip replacement) indicate that the rise will probably continue - especially because there are no legal barriers to hinder introduction of innovative treatments into routine hospital care. Upon request by payers or providers the "Gemeinsamer Bundesausschuss" may assess a treatments benefit, its necessity and cost-effectiveness as a prerequisite for coverage by the statutory health insurance. In the case of minimally-invasive disc surgery it would be advisable to examine the legal framework for covering procedures only if they are provided under evaluation conditions. While in Germany coverage under evaluation conditions is established practice in ambulatory health care only (“Modellvorhaben") examples from other European countries (Great Britain, Switzerland) demonstrate that it is also feasible for hospital based interventions. In order to assure patient protection and at the same time not hinder the further development of new and promising technologies provision under evaluation conditions could also be realised in the private health care market - although in this sector coverage is not by law linked to benefit, necessity and cost-effectiveness of an intervention.
PMCID: PMC3011322  PMID: 21289928
2.  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
3.  Endoscopic Foraminal Decompression for Failed Back Surgery Syndrome under local Anesthesia 
The most common causes of failed back surgery are residual or recurrent herniation, foraminal fibrosis and foraminal stenosis that is ignored, untreated, or undertreated. Residual back ache may also be from facetal causes or denervation and scarring of the paraspinal muscles.1–6 The original surgeon may advise his patient that nothing more can be done on the basis of his opinion that the nerve was visually decompressed by the original surgery, supported by improved post-op imaging and follow-up studies such as EMG and conduction velocity studies. Post-op imaging or electrophysiological assessment may be inadequate to explain all the reasons for residual or recurrent symptoms. Treatment of Failed back surgery by repeat traditional open revision surgery usually incorporates more extensive decompression causing increased instability and back pain, therefore necessitating fusion. The authors, having limited their practice to endoscopic MIS surgery over the last 15-20 years, report on their experience gained during that period to relieve pain by endoscopically visualizing and treating unrecognized causative patho-anatomy in FBSS.7
Thirty consecutive patients with FBSS presenting with back and leg pain that had supporting imaging diagnosis of lateral stenosis and /or residual / recurrent disc herniation, or whose pain complaint was supported by relief from diagnostic and therapeutic injections (Figure 1), were offered percutaneous transforaminal endoscopic discectomy and foraminoplasty over a repeat open procedure. Each patient sought consultation following a transient successful, partially successful or unsuccessful open translaminar surgical treatment for disc herniation or spinal stenosis. Endoscopic foraminoplasty was also performed to either decompress the bony foramen for foraminal stenosis, or foraminoplasty to allow for endoscopic visual examination of the affected traversing and exiting nerve roots in the axilla, also known as the “hidden zone” of Macnab (Figure 2).8, 9 The average follow up time was, average 40 months, minimum 12 months. Outcome data at each visit included Macnab, VAS and ODI.
A diagnostic and therapeutic epidural gram may help identify unrecognized lateral recess stenosis underestimated by MRI. An excellent result from a therapeutic block lends excellent prognosis for a more lasting and “permanent” result from transforaminal endoscopic lateral recess decompression.
Kambin's Triangle provides access to the “hidden zone” of Macnab by foraminoplasty. The foramen and lateral recess is decompressed by removing the ventral aspect and tip of the superior articular process to gain access to the axilla between the traversing and exiting nerve. FBSS contains patho-anatomy in the axilla between the traversing and exiting nerve that hides the pain generators of FBSS.
The average pre-operative VAS improved from 7.2 to 4.0, and ODI 48% to 31%. While temporary dysesthesia occurred in 4 patients in the early post-operative period, all were happy, as all received additional relief of their pre-op symptoms. They were also relieved to be able to avoid “open” decompression or fusion surgery.
Conclusions / Level of Evidence 3
The transforaminal endoscopic approach is effective for FBSS due to residual/recurrent HNP and lateral stenosis. Failed initial index surgery may involve failure to recognize patho-anatomy in the axilla of the foramen housing the traversing and the exiting nerve, including the DRG, which is located cephalad and near the tip of SAP.10 The transforaminal endoscopic approach effectively decompresses the foramen and does not further destabilize the spine needing stabilization.11 It also avoids going through the previous surgical site.
Clinical Relevance
Disc narrowing as a consequence of translaminar discectomy and progressive degenerative narrowing and spondylolisthesis (Figure 3) as a natural history of degenerative disc disease can lead to central and lateral stenosis. The MRI may underestimate the degree of stenosis from a bulging or a foraminal disc protrusion and residual lateral recess stenosis. Pain can be diagnosed and confirmed by evocative discography and by clinical response to transforaminal diagnostic and therapeutic steroid injections.12 Foraminal endoscopic decompression of the lateral recess is a MIS technique that does not “burn bridges” for a more conventional approach and it adds to the surgical armamentarium of FBSS.
Cadaver Illustration of Foraminal Stenosis (courtesy of Wolfgang Rauschning). As the disc narrows, the superior articular process impinges on the exiting nerve and DRG, creating lateral recess stenosis, lumbar spondylosis, and facet arthrosis.
PMCID: PMC4325507  PMID: 25694939
Failed Back Surgery Syndrome(FBSS); Hidden zone; Foraminal decompression; Recurrent herniation; Lateral stenosis; Foraminal osteophyte
4.  The Evolution and Advancement of Endoscopic Foraminal Surgery: One Surgeon's Experience Incorporating Adjunctive Techologies 
SAS Journal  2007;1(3):108-117.
Endoscopic spine surgery has evolved gradually through improvements in endoscope design, instrumentation, and surgical techniques. The ability to visualize and treat painful pathology endoscopically through the foramen has opened the door for the diagnosis and treatment of degenerative conditions of the lumbar spine (from T10 to S1). Other endoscopic techniques for treating a painful disc have been focused on a posterior approach and has been compared with micro–lumbar discectomy. These procedures have not been more effective than open microdiscectomy but are less invasive, have less surgical morbidity, and allow for more rapid surgical recovery. Spinal decompression and fusion was the fallback procedure when nonsurgical treatment or discectomy failed to relieve sciatica and back pain. Foraminal endoscopic surgery, however, provides a truly minimally invasive alternative approach to the pathoanatomy of the lumbar spine because it preserves the multifidus muscle, maintains motion, and eliminates or, at worst, delays the need for fusion.
The following developments helped facilitate the evolution of a transforaminal endoscopic surgery procedure for disc herniations from a foraminal disc decompression, also known as percutaneous endoscopic lumbar discectomy, to a more complete foraminal surgical technique that can address spinal stenosis and spinal instability. This expanded capability gives foraminal endoscopic surgery distinct advantages and flexibility for certain painful degenerative conditions compared with open surgery. Advancement of the technique occurred when needle trajectory and placement was refined to better target each type of herniation with precise needle and cannula positioning directed at the herniation. New instrumentation and inclusion of a biportal technique also facilitated removal of extruded, migrated, and sequestered disc herniations. The further development of foraminoscopes with larger working channels and high speed burrs to remove bone more efficiently, along with recognition of foraminal pathoanatomy in the foramen, led to the identification and treatment of other painful degenerative conditions of the lumbar spine such as failed back surgery syndrome, recurrent disc herniations, lateral foraminal stenosis, degenerative spondylolisthesis, and isthmic spondylolisthesis.
A summary of the endoscopic techniques currently used and trademarked by the author as the YESS technique include: (1) a published protocol for optimal needle and instrument placement calculated by lines drawn on the skin from the C-arm image; (2) evocative chromodiscography by the operating surgeon with nonionic radiologic contrast and indigo carmine dye to confirm concordant pain production and to stain tissue in contact with the injectate; (3) selective endoscopic discectomy, which targets the removal of loose degenerative nucleus stained differentially by indigo carmine dye; (4) thermal annuloplasty, a visualized radiofrequency thermal modulation of disc and annular defects guided by vital tissue staining; (5) endoscopic foraminoplasty, a decompression of the lateral and subarticular recess, including disc and foraminal degenerative and isthmic spondylolisthesis; (6) visually and radiologically guided exploration of the epidural space; (7) probing the hidden zone of MacNab for normal nerves (and branches of spinal nerves known as furcal nerves) versus anomalous autonomic nerves in the foramen; and (8) a uniportal and biportal technique for inside-out removal of extruded and sequestered nucleus pulposus.
Endoscopic foraminal surgical procedures are not limited to disc decompression. The approaches and techniques allow access to the lumbar spine for treatment of conditions ranging from discogenic pain to failed back surgery syndrome (most commonly caused by residual or recurrent disc herniation and lateral recess stenosis). More than 3000 patients have undergone endoscopic posterolateral surgical exploration and decompression by the author since 1991. The first 80 patients reported formed the basis for expansion of techniques as new instruments and adjunctive therapy methods were added to selective endoscopic discectomy and thermal annuloplasty. New anatomic and pathoanatomic conditions were reported as they were encountered.
New skills will become desirable and necessary for the spine surgeon to keep up with endoscopic technology in spine care. The emphasis is on visualization of painful pathoanatomy and preservation of mobility. A new focus is on nucleus replacement, annular repair, annular reinforcement, biologics, and even transforaminal interbody fusion as the procedure of last resort. The transforaminal surgical approach to the lumbar spine can allow for minimally invasive access without negatively affecting and destabilizing the multifidus muscle.
PMCID: PMC4365579  PMID: 25802587
Chymopapain; arthroscopic microdiscectomy; laser disc decompression; evocative chromodiscography; selective endoscopic discectomy; endoscopic thermal annuloplasty; endoscopic foraminoplasty
5.  Endoscopic lumbar discectomy: Experience of first 100 cases 
Indian Journal of Orthopaedics  2010;44(2):184-190.
Various modalities of treatment from standard discectomy, microdiscectomy, percutaneous discectomy, and transforaminal endoscopic discectomy have been in use for lumbar intervertebral disc prolapse. The access to spine is kept to a minimum without stripping paraspinal muscles minimizing muscle damage by posterior interlaminar endoscopic approach. The aim of this study was to evaluate technical problems, complications, and overall initial results of microendoscopic discectomy.
Materials and Methods:
First 100 consecutive cases aged 19-65 years operated by microendoscopic dissectomy between August 2002 – December 2005 are reported. All patients with single nerve root lesions including sequestrated or migrated and selected central disc at L4-5 and L5-S1 were included. The patients with bilateral radiculopathy were excluded. All patients had preoperative MRI and first 11 patients had postoperative MRI to check the adequacy of decompression. Diagnostic selective nerve root blocks were done in selective cases to isolate the single root lesion when MRI was inconclusive (n=7). All patients were operated by a single surgeon with the Metrx system (Medtronics). 97 were operated by 18-mm ports, and only three patients were operated by 16-mm ports. Postoperatively, all patients were mobilized as soon as the pain subsided and discharged within 24–48 h postsurgery. Patients were evaluated for technical problems, complications, and overall results by modified Macnab criteria. Patients were followed up at 2, 6, and 12 weeks.
The mean follow up was 12 months (range 3 months – 4 years). Open conversion was required in one patient with suspected root damage. Peroperatively single facet removal was done in 5 initial cases. Minor dural punctures occurred in seven cases and root damage in one case. The average surgical time was 70 min (range 25-210 min). Average blood loss was 20-30 ml. Technical difficulties encountered in initial 25 cases were insertion of guide pin, image orientation, peroperative dissection and bleeding problems, and reaching wrong levels suggestive of a definitive learning curve. Postoperative MRI (n=11) showed complete decompression. Overall 91% of patients had good-to-excellent results, with four patients having recurrence of whom three were reoperated. Four patients had postoperative discitis. One of the patients required fusion for discitis and rest were managed conservatively. One patient had root damage to L5 root that had paresthesia in L5 region even on 4 years of follow-up.
Microendoscopic discectomy is minimally invasive procedure for discectomy with early encouraging results. Once definite learning curve was over and expertise is acquired, the results of this procedure are acceptable safe and effective.
PMCID: PMC2856394  PMID: 20419006
Lumbar discectomy; microendo system; endoscopic lumbar discectomy
6.  Microendoscopic lumbar discectomy: Technique and results of 188 cases 
Indian Journal of Orthopaedics  2014;48(1):81-87.
Discectomy performed open or with an operating microscope remains the standard surgical management. Tubular retractor system is being increasingly used. Potential benefits include less muscle and local damage, better cosmesis, decreased pain and operative time and faster recovery after surgery. We have evaluated the outcome of micro endoscopic discectomy (MED) utilizing tubular retractors in terms of safety and efficacy of the technique.
Materials and Methods:
188 consecutive patients who underwent surgery for herniated disc using the tubular retractors between April 2007 and April 2012 are reported. All patients had a preoperative MRI (Magnetic Resonance Imaging) and were operated by a single surgeon with the METRx system (Medtronic, Sofamor-Danek, Memphis, TN) using 18 and 16 mm ports. All patients were mobilized as soon as pain subsided and discharged within 24-48 hours post surgery. The results were evaluated by using VAS (Visual Analog Scale 0-5) for back and leg pain and ODI (Oswestry Disability Index). Patients were followed up at intervals of 1 week, 6 weeks, 3 months, 6 months, 12 months and 2 years.
The mean age of patients was 46 years (range 16-78 years) and the sex ratio was 1.5 males to 1 female. The mean followup was 22 months (range 8-69 months). The mean VAS scale for leg pain improved from 4.14 to 0.76 (P < 0.05) and the mean VAS scale for back pain improved from 4.1 to 0.9 (P < 0.05). The mean ODI changed from 59.5 to 22.6 (P < 0.05). The mean operative time per level was about 50 minutes (range 20-90 minutes). Dural punctures occurred in 11 (5%) cases. Average blood loss was 30 ml (range 10-500 ml). A wrong level was identified and later corrected in a case of revision discectomy. Four patients with residual disc-herniation had revision MED and three patients with recurrent disc herniation later underwent fusion. One patient had wound infection which needed a debridement.
MED for herniated discs effectively achieves the goals of surgery with minimal access. The advantages of the procedure are cosmesis, early postoperative recovery and minimal postoperative morbidity.
PMCID: PMC3931158  PMID: 24600068
Herniated nucleus pulposus (HNP); micro endoscopic discectomy; minimal invasive spine surgery
7.  Early Postoperative Results after Removal of Cranially Migrated Lumbar Disc Prolapse: Retrospective Comparison of Three Different Surgical Strategies 
Advances in Orthopedics  2014;2014:702163.
Background. To compare the early postoperative results of three surgical approaches to lumbar disc herniations that migrated cranially. Minimally invasive techniques such as the translaminar and endoscopic transforaminal approaches are utilized in patients with lumbar disc herniations to gain access to cranially located disc material and to avoid the potentially destabilizing resection of ligament and bone tissue, which is associated with an extended interlaminar approach. Methods. This retrospective study compares the postoperative pain and functional capacity levels of 69 patients who underwent an interlaminar (Group A, n = 27), a translaminar (Group B, n = 22), or an endoscopic transforaminal procedure (Group C, n = 20). Results. Median VAS scores for leg pain decreased significantly from before to after surgery in all groups. Surgical revisions were required in thirteen cases (five in Group A, one in Group B, and seven in Group C; P = 0.031). After six weeks, there were significant differences in back pain and functional outcome scores and in the results for the MacNab criteria but not in leg pain scores. Conclusions. The interlaminar and translaminar techniques were the safest and fastest ways of gaining access to cranially migrated disc material and the most effective approaches over a period of six weeks.
PMCID: PMC4247947  PMID: 25478234
8.  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
9.  Symptomatic Post-Discectomy Pseudocyst after Endoscopic Lumbar Discectomy 
The objectives of this study were to determine the frequency of symptomatic postdiscectomy pseudocyst (PP) after endoscopic discectomy and to compare the results of surgical and conservative management of them.
Initial study participants were 1,503 cases (1,406 patients) receiving endoscopic lumbar discectomy by 23-member board of neurosurgeons from March 2003 to October 2008. All patients' postoperative magnetic resonance imaging (MRI) scans were evaluated. On the postoperative MRI, cystic lesion of T2W high and T1W low at discectomy site was regarded as PP. Reviews of medical records and radiological findings were done. The PP patients were divided into two groups, surgical and conservative management by treatment modality after PP detection. We compared the results of the two groups using the visual analogue scale (VAS) for low back pain (LBP), VAS for leg pain (LP) and the Oswestry disability index (ODI).
Among 1,503 cases of all male soldiers, the MRIs showed that pseudocysts formed in 15 patients, about 1.0% of the initial cases. The mean postoperative interval from surgery to PP detection was 53.7 days. Interlaminar approach was correlated with PP formation compared with transforaminal approach (p=0.001). The mean VAS for LBP and LP in the surgical group improved from 6.5 and 4.8 to 2.0 and 2.3, respectively. The mean VAS for LBP and LP in the conservative group improved from 4.4 and 4.4 to 3.9 and 2.3, respectively. There was no difference in treatment outcome between surgical and conservative management of symptomatic PP.
Although this study was done in limited environment, symptomatic PP was detected at two months' postoperative period in about 1% of cases. Interlaminar approach seems to be more related with PP compared with transforaminal approach.
PMCID: PMC3070892  PMID: 21494360
Endoscopic discectomy; Herniated disc; Lumbar; Postoperative complication; Pseudocyst
10.  An Analysis of the Prognostic Factors Affecing the Clinical Outcomes of Conventional Lumbar Open Discectomy : Clinical and Radiological Prognostic Factors 
Asian Spine Journal  2010;4(1):23-31.
Study Design
This is a retrospective study.
We wanted to examine the clinical and radiological prognostic factors affecting the postoperative clinical outcome of patients with lumbar disc herniation and who underwent open discectomy.
Overview of Literature
Conventional open discectomy has been widely used as a treatment regimen for the management of lumbar disc herniation. Still, much controversy exists regarding the factors that affect the postoperative clinical outcomes.
The current study was conducted on 40 patients who were diagnosed with lumbar disc herniation by the senior surgeon of our department from March 2004 to June 2007. These patients were refractory to conservative treatment and they could be followed up for more than one year following their surgical treatments. Preoperatively, after postoperative year 1 and at the final follow-up, a comparison was made for the Oswestry disability index (ODI) scores and the visual analogue scale (VAS) scores that indicated low back pain and radiating pain. For identifying prognostic factors, an analysis was also performed for such factors as age, gender, the operated level, the duration of preoperative low back pain and radiating pain, a smoking history, the body mass index and whether the surgery was revision or the primary operation. A radiological analysis, based on the preoperative plain flexion-extension radiography, was performed for the presence of mild segmental instability of < 3 mm, spondylolysis and disc space narrowing. Pfirrmann's degenerative grade of the disc, the degree of herniation and whether a herniation was central or massive on the magnetic resonance imaging scans.
At the final follow-up, the ODI was significantly higher in the cases of revision as compared with the cases of primary operation. The female gender also had a tendency for a poor ODI as compared with that of the men, but this had only borderline statistical significance. There was significant correlation between the preoperative ODI and the preoperative VAS indicating radiating pain. At a final follow up, the low back pain VAS score was significantly lower in the extruded cases as compared with that of the protruded or sequestrated cases.
Following an analysis for detecting the prognostic factors of open discectomy, the final clinical outcome was found to be poor for the revision surgery cases. In regard to the type of herniation, the degree of low back pain was relatively lower at a final follow-up for the extruded cases as compared with that for the protruded or sequestrated cases. Open discectomy surgery should be performed after evaluating the patients' various prognostic factors that could affect the final clinical outcome.
PMCID: PMC2900165  PMID: 20622951
Lumbar disc herniation; Open discectomy; Clinical outcome; Prognostic factor
11.  Full-endoscopic interlaminar removal of chronic lumbar epidural hematoma after spinal manipulation 
Spinal manipulation is widely used for low back pain treatments. Complications associated with spinal manipulation are seen. Lumbar epidural hematoma (EDH) is one of the complications reported in the literature. If lumbar chronic EDH symptoms are present, which are similar to those of a herniated nucleus pulposus, surgery may be considered if medical treatment fails. Percutaneous endoscopic discectomy utilizing an interlaminar approach can be successfully applied to those with herniated nucleus pulposus. We use the same technique to remove the lumbar chronic EDH, which is the first documented report in the related literature.
We present a case with chronic lumbar EDH associated with spinal manipulation. Neurologic deficits were noted on physical examination. We arranged for a full-endoscopic interlaminar approach to remove the hematoma for the patient with the rigid endoscopy (Vertebris system; Richard Wolf, Knittlingen, Germany).
After surgery, the patient's radiculopathy immediately began to disappear. Magnetic resonance imaging (MRI) follow-up 10 days after the surgery revealed no residual hematoma. No complications were noted during the outpatient department follow up.
Lumbar EDH is a possible complication of spinal manipulation. Patient experiencing rapidly progressive neurologic deficit require early surgical evacuation, while conservative treatment may only be applied to those with mild symptoms. A percutaneous full-endoscopic interlaminar approach may be a viable alternative for the treatment of those with chronic EDH with progressive neurologic deficits.
PMCID: PMC4033759  PMID: 24872917
Chronic epidural hematoma; endoscopic; interlaminar; lumbar; spinal manipulation
12.  Analysis of Efficacy Differences between Caudal and Lumbar Interlaminar Epidural Injections in Chronic Lumbar Axial Discogenic Pain: Local Anesthetic Alone vs. Local Combined with Steroids 
Study Design: Comparative assessment of randomized controlled trials of caudal and lumbar interlaminar epidural injections in chronic lumbar discogenic pain.
Objective: To assess the comparative efficacy of caudal and lumbar interlaminar approaches of epidural injections in managing axial or discogenic low back pain.
Summary of Background Data: Epidural injections are commonly performed utilizing either a caudal or lumbar interlaminar approach to treat chronic lumbar axial or discogenic pain, which is pain exclusive of that associated with a herniated intervertebral disc, or that is due to degeneration of the zygapophyseal joints, or due to dysfunction of the sacroiliac joints, respectively. The literature on the efficacy of epidural injections in managing chronic axial lumbar pain of presumed discogenic origin is limited.
Methods: The present analysis is based on 2 randomized controlled trials of chronic axial low back pain not caused by disc herniation, radiculitis, or facet joint pain, utilizing either a caudal or lumbar interlaminar approach, with a total of 240 patients studied, and a 24-month follow-up. Patients were assigned to receive either local anesthetic only or local anesthetic with a steroid in each 60 patient group.
Results: The primary outcome measure was significant improvement, defined as pain relief and functional status improvement of at least 50% from baseline, which was reported at 24-month follow-ups in 72% who received local anesthetic only with a lumbar interlaminar approach and 54% who received local anesthetic only with a caudal approach. In patients receiving local anesthetic with a steroid, the response rate was 67% for those who had a lumbar interlaminar approach and 68% for those who had a caudal approach at 12 months. The response was significantly better in the lumbar interlaminar group who received local anesthetic only, 77% versus 56% at 12 months and 72% versus 54% at 24 months.
Conclusion: This assessment shows that in patients with axial or discogenic pain in the lumbar spine after excluding facet joint and SI Joint pain, epidural injections of local anesthetic by the caudal or lumbar interlaminar approach may be effective in managing chronic low back pain with a potential superiority for a lumbar interlaminar approach over a caudal approach.
PMCID: PMC4323359  PMID: 25678838
Chronic low back pain; axial low back pain; lumbar discogenic pain; caudal epidural injections; lumbar interlaminar epidural injections.
13.  Endoscopic Transforaminal Thoracic Foraminotomy and Discectomy for the Treatment of Thoracic Disc Herniation 
Minimally Invasive Surgery  2013;2013:264105.
Thoracic disc herniation is a relatively rare yet challenging-to-diagnose condition. Currently there is no universally accepted optimal surgical treatment for symptomatic thoracic disc herniation. Previously reported surgical approaches are often associated with high complication rates. Here we describe our minimally invasive technique of removing thoracic disc herniation, and report the primary results of a series of cases. Between January 2009 and March 2012, 13 patients with symptomatic thoracic disc herniation were treated with endoscopic thoracic foraminotomy and discectomy under local anesthesia. A bone shaver was used to undercut the facet and rib head for foraminotomy. Discectomy was achieved by using grasper, radiofrequency, and the Holmium-YAG laser. We analyzed the clinical outcomes of the patients using the visual analogue scale (VAS), MacNab classification, and Oswestry disability index (ODI). At the final follow up (mean: 17 months; range: 6–41 months), patient self-reported satisfactory rate was 76.9%. The mean VAS for mid back pain was improved from 9.1 to 4.2, and the mean ODI was improved from 61.0 to 43.8. One complication of postoperative spinal headache occurred during the surgery and the patient was successfully treated with epidural blood patch. No other complications were observed or reported during and after the surgery.
PMCID: PMC3880763  PMID: 24455232
14.  Endoscopic Transforaminal Suprapedicular Approach in High Grade Inferior Migrated Lumbar Disc Herniation 
Although endoscopic procedures for lumbar disc diseases have improved greatly, the postoperative outcomes for high grade inferior migrated discs are not satisfactory. Because of anatomic limitations, a rigid endoscope cannot reach all lesions effectively. The purpose of this study was to determine the feasibility of endoscopic transforaminal suprapedicular approach to high grade inferior-migrated lumbar disc herniations.
Between May 2006 and March 2008, a suprapedicular approach was performed in 53 patients with high grade inferior-migrated lumbar disc herniations using a rigid endoscope and a semi-rigid flexible curved probe. One-to-four hours after surgery, the presence of remnant discs was checked with MRI. The outcomes were evaluated with the visual analogue scale (VAS) score and the Oswestry Disability Index (ODI) one week after surgery.
The L2-3 level was involved in 2 patients and the L3-4 level was involved in 14 patients, while the L4-5 level was involved in 39 patients. There were single piece-type in 34 cases and a multiple piece-type in 19 cases. Satisfactory results were obtained in all cases. The mean preoperative VAS for leg pain was 9.32±0.43 points (range, 7-10 points), whereas the mean ODI was 79.82±4.53 points (range, 68-92 points). At the last follow-up examination, the mean postoperative VAS for leg pain was 1.78±0.71 points and the mean postoperative ODI improved to 15.27±3.82 points.
A high grade inferior migrated lumbar disc is difficult to remove sufficiently by posterolateral endoscopic lumbar dscectomy using a rigid endoscope. However, a satisfactory result can be obtained by applying a transforaminal suprapedicular approach with a flexible semi-rigid curved probe.
PMCID: PMC2651558  PMID: 19274114
Migrated disc herniation; Percutaneous endoscopic lumbar discectomy; Rigid endoscope; Flexible curved probe
15.  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
16.  Comparative Study of the Outcomes of Percutaneous Endoscopic Lumbar Discectomy and Microscopic Lumbar Discectomy Using the Tubular Retractor System Based on the VAS, ODI, and SF-36 
Korean Journal of Spine  2012;9(3):215-222.
Percutaneous endoscopic lumbar discectomy (PELD) and microdiscectomy with the microscope endoscopic tubular retractor system(METRx-MD) are considered popular minimally invasive surgery (MIS) methods for the treatment of lumbar disc herniation. Many authors have also reported good clinical outcomes of these methods, but there are few comparative studies of them. This report compares the clinical outcomes of PELD and METRx-MD for lumbar disc herniation as MIS methods and discusses the efficacy of PELD.
Seventy-two patients who had undergone single-level unilateral discectomy using two different methods, PELD and METRx-MD, between 2009 and 2011 were given a follow-up examination prospectively. Thirty-seven of these patients underwent discectomy using PELD, and the remaining 35 patients underwent discectomy using METRx-MD. In addition to the general parameters, clinical outcomes were assessed as specific parameters using the Visual Analogue Scale (VAS) score, the Oswestry Disability Index (ODI), the Short-form 36 (SF-36), and the return-to-work time.
Sixty-seven percent (25/37) of the patients in the PELD group and 74%(26/35) in the METRx-MD group were included in follow-up more than 6 months post-operatively. The mean improvements in the VAS scores for the back pain, leg pain, and ODI were 2.6, 4.8, and 30.1% for the PELD group and 2.8, 4.6, and 33.2% for the METRx-MD group, respectively. The SF-36 physical health component subscale score improved from 40.6 pre-operatively to 68.3 at the last follow-up for the PELD group post-operatively, and from 48.5 to 65.1 in the mental component subscale (METRx-MD group: from 34.4 to 66.5 and from 44.87 to 56.7). Complications occurred in 3/37 patients in the PELD group and in 2/35 patients in the METRx-MD group in the peri-operative period. The mean return-to-work times were 37.5 days in the PELD group and 42.5 days in the METRx-MD group.
The outcomes for the PELD group are comparable to those for the METRx-MD group. It can thus be concluded that PELD for lumbar disk herniations may be performed safely and effectively. Also, PELD can be considered one of the treatment modalities of lumbar disk herniation.
PMCID: PMC4431005  PMID: 25983818
Percutaneous discectomy; Microdiscectomy; Lumbar disc herniation; VAS; ODI; SF-36
17.  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
18.  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
19.  Minimally invasive percutaneous endoscopic 2 levels adjacent lumbar discectomy through 1 portal skin incision: Preliminary study 
Asian Journal of Neurosurgery  2015;10(2):95-101.
Acute lumbar disc herniation can occur in every lumbar intervertebral disc space and in multiple levels simultaneously. In the cases of 2 levels adjacent lumbar disc herniations of severe unilateral radiculopathic leg pain caused by compression of the nerve roots, respectively, multiple incision or long incision is generally needed for simultaneous removal of disc fragment in 2 levels.
We proposed the minimally invasive one portal skin incision endoscopic discectomy is effective and safe method to treat 2 levels adjacent lumbar disc herniation.
Materials and Methods:
We have experimented total 8 cases of 2 levels adjacent lumbar disc herniation having unilateral radiculopathic pain respectively. All cases are 2 levels adjacent lumbar disc herniation. We have tried a percutaneous endoscopic transforaminal approach through minimal one portal skin incision and remove the two herniated disc materials in the adjacent levels.
The L2-L3 level was involved in 2 patients, L3-L4 level in 6 patients, while the L4-L5 level was involved in 7 patients, L5-S1 level in 1 patient. The mean follow-up was 18.5 months. The mean visual analogue score (VAS) of the patients prior to surgery was 7.75, and the mean postoperative VAS was 2.375. According to Macnab's criteria, 3 patients had excellent results, 4 patients had good results, 1 patient had fair results, and no patient had a poor result; satisfactory results were obtained in 87.5% of the cases.
The percutaneous endoscopic transforaminal approach through 1 skin portal incision could be effective surgical method in unilateral adjacent 2 levels lumbar disc herniation.
PMCID: PMC4421975  PMID: 25972937
Adjacent 2 levels disc herniation; one portal; percutaneous endoscopic lumbar discectomy; transforaminal approach
20.  Clinical Outcomes of Percutaneous Endoscopic Surgery for Lumbar Discal Cyst 
Discal cyst is rare and causes indistinguishable symptoms from lumbar disc herniation. The clinical manifestations and pathological features of discal cyst have not yet been completely known. Discal cyst has been treated with surgery or with direct intervention such as computed tomography (CT) guided aspiration and steroid injection. The purpose of this study is to evaluate the safety and efficacy of the percutaneous endoscopic surgery for lumbar discal cyst over at least 6 months follow-up.
All 8 cases of discal cyst with radiculopathy were treated by percutaneous endoscopic surgery by transforaminal approach. The involved levels include L5-S1 in 1 patient, L3-4 in 2, and L4-5 in 5. The preoperative magnetic resonance imaging and 3-dimensional CT with discogram images in all cases showed a connection between the cyst and the involved intervertebral disc. Over a 6-months period, self-reported measures were assessed using an outcome questionaire that incorporated total back-related medical resource utilization and improvement of leg pain [visual analogue scale (VAS) and Macnab's criteria].
All 8 patients underwent endoscopic excision of the cyst with additional partial discectomy. Seven patients obtained immediate relief of symptoms after removal of the cyst by endoscopic approach. There were no recurrent lesions during follow-up period. The mean preoperative VAS for leg pain was 8.25±0.5. At the last examination followed longer than 6 month, the mean VAS for leg pain was 2.25±2.21. According to MacNab' criteria, 4 patients (50%) had excellent results, 3 patients (37.5%) had good results; thus, satisfactory results were achieved in 7 patients (87.5%). However, one case had unsatisfactory result with persistent leg pain and another paresthesia.
The radicular symptoms were remarkably improved in most patients immediately after percutaneous endoscopic cystectomy by transforaminal approach.
PMCID: PMC3377877  PMID: 22737300
Lumbar discal cyst; Percutaneous endoscopic transforaminal cystectomy
21.  Epidural steroid injection in patients with lumbosacral radiculopathy in Abuja, Nigeria 
This prospective-controlled observational study looked at well-matched patients with spinal pain and radicular symptoms, caused by lumbar intervertebral disc herniation to compare the short-term clinical outcome of transforaminal and interlaminar epidural steroid injection (ESI) in a resource challenged tertiary institution in Nigeria.
Materials and Methods:
49 patients with radicular symptoms who were matched for age, symptom duration, magnetic resonance imaging findings, and pre-injection revised Oswentry Disability Index (ODI) score and Visual Analogue Scale (VAS) were assigned into ESI technique. The ODI and VAS score were analyzed immediately after an injection and upon follow-up (average 178.5 days), also with the need for repeated injections and surgical interventions over a 1-year follow-up interval.
In the transforaminal group (25 patients), there was a statistically significant improvement in the ODI scores from before the injection (ODI mean 62.4) to immediately after the injection (ODI mean 24.4, P < 0.01), and upon follow-up (ODI mean 20.8, P < 0.01). 9 patients (18.4%) required 1 or 2 repeated injections, 3 (6.1%) patients underwent surgery and 2 (4%) patients lost to follow-up. In the interlaminar group (24 patients), there was a statistically significant improvement in the ODI scores from before the injection (ODI mean 60.7) to immediately after the injection (ODI mean 30.1, P < 0.01), but not upon follow-up (ODI mean 43.2, P = 0.09). 11 (22.4%) patients required 1 or 2 repeated injection, 4 (8%) patients underwent surgery and 3 (6.1%) patients were lost to follow-up. There is an average of 2 fold improvement of transforaminal ESI over interlaminar ESI in a 40 point scale of ODI score on follow-up, which was statistically significant (P < 0.01). The VAS showed similar pattern with the ODI scores in the study.
Transforaminal ESI to treat symptomatic lumbar disc herniation resulted in better short-term pain improvement and fewer long-term surgical interventions compared to interlaminar ESI.
PMCID: PMC3409978  PMID: 22865959
Epidural injections; oswentry disability index; spinal pain
22.  Clinical outcomes and efficacy of transforaminal lumbar endoscopic discectomy 
Transforaminal lumbar endoscopic discectomy (TLED) is a minimally invasive procedure for removing lumbar disc herniations. This technique was initially reserved for herniations in the foraminal or extraforaminal region. This study concentrated on our experience regarding the outcomes and efficacy of TLED.
Materials and Methods:
A total of 105 patients were included in the study. The patients were retrospectively evaluated for demographic features, lesion levels, numbers of affected levels, visual analog scores (VASs), Oswestry disability questionnaire scale scores and MacNab pain relief scores.
A total of 48 female and 57 male patients aged between 25 and 64 years (mean: 41.8 years) underwent TLED procedures. The majority (83%) of the cases were operated on at the levels of L4-5 and L5-S1. Five patients had herniations at two levels. There were significant decreases between the preoperative VAS scores collected postoperatively at 6 months (2.3) and those collected after 1-year (2.5). Two patients were referred for microdiscectomy after TLED due to unsatisfactory pain relief on the 1st postoperative day. The overall success rate with respect to pain relief was 90.4% (95/105). Seven patients with previous histories of open discectomy at the same level reported fair pain relief after TLED.
Transforaminal lumbar endoscopic discectomy is a safe and effective alternative to microdiscectomy that is associated with minor tissue trauma. Herniations that involved single levels and foraminal/extraforaminal localizations were associated with better responses to TLED.
PMCID: PMC4481788  PMID: 26167017
Endoscopic discectomy; lumbar spine; revision; transforaminal
23.  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
24.  Effectiveness of percutaneous laser disc decompression versus conventional open discectomy in the treatment of lumbar disc herniation; design of a prospective randomized controlled trial 
The usual surgical treatment of refractory sciatica caused by lumbar disc herniation, is open discectomy. Minimally invasive procedures, including percutaneous therapies under local anesthesia, are increasingly gaining attention. One of these treatments is Percutaneous Laser Disc Decompression (PLDD). This treatment can be carried out in an outpatient setting and swift recovery and return to daily routine are suggested. Thus far, no randomized trial into cost-effectiveness of PLDD versus standard surgical procedure has been performed. We present the design of a randomized controlled trial, studying the cost-effectiveness of PLDD versus conventional open discectomy in patients with sciatica from lumbar disc herniation.
The study is a randomized prospective multi-center trial, in which two treatment strategies are compared in a parallel group design. Patients (age 18–70 years) visiting the neurosurgery department of the participating hospitals, are considered for inclusion in the trial when sciatica due to lumbar disc herniation has lasted more than 8 weeks. Patients with disc herniation smaller than 1/3 of the spinal canal diameter, without concomitant lateral recess stenosis or sequestration, are eligible for participation, and are randomized into one of two treatment arms; either Percutaneous Laser Disc Decompression or conventional discectomy. The functional outcome of the patient, as assessed by the Roland Disability Questionnaire for Sciatica at 8 weeks and 1 year after treatment, is the primary outcome measure. The secondary outcome parameters are recovery as perceived by the patient, leg and back pain, incidence of re-intervention, complications, quality of life, medical consumption, absence of work and secondary costs.
Open discectomy is still considered to be the golden standard in the surgical treatment of lumbar disc herniation. Whether Percutaneous Laser Disc Decompression has at least as much efficacy as the standard surgical procedure, and is more cost-effective, will be determined by this trial.
Trial registration
Current Controlled Trials ISRCTN25884790.
PMCID: PMC2697136  PMID: 19439098
25.  Higher preoperative Oswestry Disability Index is associated with better surgical outcome in upper lumbar disc herniations 
European Spine Journal  2007;17(1):117-121.
To evaluate the surgical outcome in terms of functional and subjective recovery, patients who needed discectomies at L1–L2, L2–L3 and L3–L4 levels were compared with an age and sex-matched group of patients who required L4–L5 and L5–S1 discectomies. We prospectively enrolled 50 consecutive patients, referred to our center, who had L1–L2, L2–L3 and L3–L4 herniations and required surgical intervention. Likewise, a comparative group of 50 consecutive patients with herniations at L4–L5 and L5–S1 were selected. All 100 patients were treated and followed for a 1 year period. Physical examination findings as well as Oswestry Disability Questionnaire before surgery were recorded. After 1 year, patients were requested to fill the same questionnaire. Significant decline in the Oswestry Disability Index (ODI) scores was considered to be a measure of functional improvement and recovery. The mean age of patients with upper lumbar disc herniation (L1–L2, L2–L3, L3–L4) was 45.7 years and patients with lower lumbar disc herniation (L4–L5, L5–S1) had a mean age of 41.2 years. There was no statistically significant difference in age between the two groups. The preoperative Oswestry Disability (ODI) Index score had a statistically significant impact on ODI score improvement after surgery in both lower and upper lumbar disc groups. All 100 patients with either lower or upper lumbar disc herniation had statistically significant ODI change after surgical intervention (P < 0.0001 for both groups). However, patients with upper disc herniations and moderate preoperative disability (ODI of 21–40%) did not show significant improvement, while patients with ODI greater than 40% had significant reduction (P = 0.018). Surprisingly, as many as 25% of the former had even an increase in ODI scores after surgery. Gender was also a conspicuous factor in determining the surgical outcome of patients with upper lumbar disc herniation, and male patients had more reduction in ODI score than female patients (P = 0.007). Since the functional recovery in patients with herniated lumbar disc, especially upper lumbar herniation, is influenced by preoperative ODI scores, the use of ODI or any other standard pain assessment tool is a sensible consideration as an inherent investigative method to preclude unfavorable surgical outcome.
PMCID: PMC2365528  PMID: 17972115
Upper lumbar disc; Oswestry Disability Index; Surgical outcome

Results 1-25 (992775)