ReviewPercutaneous endoscopic lumbar discectomy for lumbar disc herniation
Introduction
Lumbar intervertebral disc herniation (LDH) is a clinically symptomatic condition caused by the compression of spinal nerve roots by protruded disc material. The main symptom of LDH is low back pain and sciatica [1]. It has been reported that almost 80% of the adults in China were suffering from low back and leg pain and about 20% of them were diagnosed with LDH [2].
For most of the patients, low back and leg pain could be alleviated with traction, massage or other conservative methods. However in the 10% to 20% of patients with symptoms that persist after a period of conservative therapy, surgical treatment should be considered [3]. Surgery for LDH can be classified into open discectomy (OD) and minimally invasive surgery. OD is aiming at resecting the herniation of the disc tissue compressing the nerve root or spinal cord (with or without a microscope magnification) through a posterior approach. The OD has been regarded as a standard surgical (SD) treatment for LDH for many years, dating back to 1934 when Mixter and Barr reported partial laminectomy and partial removal of the disc for the treatment of LDH [4]. In 1977, with the introduction of the microscope, Caspar and Yasargil refined the traditional laminectomy into a more minimally invasive open microdiscectomy [5], [6]. Since that time SD has become one of the most widespread techniques for surgical decompression of radiculopathy caused by LDH.
PELD is one of the typical represented minimal invasive discectomy operation, which removes the affected disc under local anesthesia while avoiding to removing the lamina, destroying the paraspinal muscles and ligaments and interfering with the spinal canal. One benefit of PELD is that it prevents postoperative segment instability and slippage which is different from the open posterior approach. PELD can be sub-classified into the percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID) according to the approach to the herniation disc materials. PELD has caught a large amount of attention in the spine surgery field since it was introduced. When referring to the question of which operation could achieve a better clinical effect between PELD and SD, current opinions vary. Kim [7] reported similar clinical outcomes from the two techniques. Iprenburg [8] showed that the outcome of visual analogue scale (VAS) scores for back and leg pain and patient satisfaction in the PELD group were better than the SD group. At the same time, they reported that the incidence of recurrence and reoperation between PELD and SD was also variable.
With the popularity of PELD in the spine surgery further evidence of its safety and efficacy as compared to SD is necessary. Until now, only two studies [9], [10] have reviewed the literature regarding PETD for symptomatic LDH. Ambiguous results have clouded the evidence regarding whether PELD is superior to SD. Therefore, our goal was to acquire more reliable evidence by performing a meta-analysis summarizing recent literature for comparing PELD and SD.
Section snippets
Inclusion criteria
Studies were included if they met the following criteria: randomized or non-randomized controlled clinical studies; adult patients over 18 years of age with diagnosis of LDH; studies compared SD (open discectomy, partial laminectomy, hemilaminectomy and open microdiscectomy) with PELD (PETD, PEID) for the treatment of LDH; every patient had been diagnosed with single segmental intervertebral disc herniation based on physical examinations and imaging tests (computed tomography, magnetic resonance
Search results
The flow diagram detailing studies included and excluded are illustrated in Figure 1. At the primary search of electronic database searches, a total of 2396 relevant studies were identified. After reviewing titles and abstracts, 2351 studies were excluded. An additional 32 studies were excluded for failing to meet the inclusion criteria.
The remaining seven studies [7], [13], [14], [15], [16], [17], [18] including 1301 cases (488 cases for the group of PELD and 813 cases for the SD group)
Discussion
In general, when compared with SD, the potential advantages of PELD include: (1) Can be performed under a local anesthesia, (2) Reduced tissue trauma and minimal disturbance of the intracanal capsular structures, (3) Immediate postoperative recovery and lower cost [19], [20], [21]. Despite the promising techniques of PELD with successful outcomes comparable to conventional standard open surgery [13], [22], [23], [24], consensus among spine surgeons is still lacking. Most of the concerns about
Conclusion
To our knowledge, this is the first meta-analysis to compare PELD with SD for the treatment of LDH. Based on this analysis, the following conclusions may be drawn: the clinical outcomes of PELD cases are superior to SD for blood loss, operative time, hospital stay, mean disability period. However, the outcomes of VAS scores, MacNab, complications, recurrence rate, and reoperation are equivalent between the two groups. Therefore, we suggest that PELD can be a feasible alternative to the
Conflicts of Interest/Disclosures
Support: This paper was supported by grants from National Natural Science Foundation of China (no.81171700), Li-Jun Li. The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.
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These authors have contributed equally to the manuscript.