Elsevier

World Neurosurgery

Volume 113, May 2018, Pages e638-e649
World Neurosurgery

Original Article
Percutaneous Transforaminal Endoscopic Discectomy for the Treatment of Lumbar Disc Herniation in Obese Patients: Health-Related Quality of Life Assessment in a 2-Year Follow-Up

https://doi.org/10.1016/j.wneu.2018.02.112Get rights and content

Highlights

  • PTED should be carefully considered in obese patients with LDH.

  • Serious technical challenges may increase the complication rate.

  • PTED may be further considered in specific obese patients.

  • Obese patients demonstrate lesser and more gradual clinical improvement.

  • Acquisition of favorable outcomes presupposes the surgeon's experience with performing PTED.

Background

Percutaneous transforaminal endoscopic discectomy (PTED) is a minimally invasive surgical technique used principally for the treatment of lumbar disc herniation (LDH). LDH is a frequent spinal ailment in obese individuals. The aim of this prospectively designed study was to assess for the first time in the literature the impact of PTED in postoperative parameters of health-related quality of life (HRQoL) in obese patients with LDH within a 2-year follow-up period, to further evaluate the effectiveness of PTED.

Methods

Patients with surgically treatable LDH were divided into 2 groups. Group A constituted 20 obese patients, and group B was composed of 10 patients with normal body mass index (BMI). A visual analog scale was used for pain evaluation, and the Short Form SF-36 Medical Survey Questionnaire contributed to HRQoL assessment. Follow-up was conducted preoperatively and at 6 weeks and 3, 6, 12, and 24 months postoperatively.

Results

Two of the 20 patients (10%) presented with severe postoperative pain, necessitating conventional microdiscectomy. All studied parameters exhibited maximal improvement at 6 months in group A and at 6 weeks in group B, with subsequent stabilization. Obese patients scored lower in all parameters compared with their healthy counterparts with normal BMI, acquiring a less favorable clinical benefit.

Conclusions

PTED appears to be a generally safe and effective method for treating obese patients with LDH. However, major technical challenges that lead to a higher frequency of complications, as well as the lesser acquired clinical benefit, in obese patients may contribute to the further consideration for PTED in specific obese patients, especially on the grounds of low surgical experience.

Introduction

Obesity is a dominant public health problem with increasing prevalence.1 According to body mass index (BMI), a widely used parameter for robust evaluation of body fat, a BMI of 18.5–22.9 kg/m2 is considered normal body weight,2 a BMI of 25–29.9 kg/m2 is defined as overweight, and a BMI of ≥30 kg/m2 is defined as obesity.3 Elevated BMI is associated with overloading of the musculoskeletal system, especially affecting the lumbar spine.4, 5 Obesity has been established as a risk factor for lumbar disc herniation (LDH).2 Increased pressures can damage the integrity of intervertebral discs.6 Degenerative alterations of intervertebral discs seem to constitute the salient etiology for onset of low back pain (LBP).1 LBP affects 80% of the general population and is considered a significant socioeconomic problem.7

Minimal invasive spine surgery provides a beneficial alternative to conventional surgical approaches in the obese population.8 Percutaneous transforaminal endoscopic discectomy (PTED) is a rapidly evolving surgical technique in the field of LDH treatment. This surgical technique provides spine surgeons with the ability to approach the epidural space through the intervertebral foramen, enabling work in the anatomic triangle (safe zone).9 PTED is associated with less soft tissue trauma, preservation of dorsal musculature, shorter hospitalization times, reduced perioperative morbidity, and earlier return to work.10, 11

To the best of our knowledge, PTED in obese patients with LDH has been reported in only 2 previous publications, with parallel demonstrations of outcomes and safety.2, 8 However, evaluation of the efficacy of PTED included only the assessment of pain and neurologic function in both cases. Neither of the studies reported specific results regarding the impact of PTED on the patients' postoperative quality of life. The aim of the present study was to evaluate outcomes of PTED after 2 years of follow-up in a cohort of obese patients. This is the first report on assessment of health-related quality of life (HRQoL) after PTED in obese patients with LDH using the Short-Form 36 (SF-36) medical health survey questionnaire.

Section snippets

Study Population

Our study cohort included patients with LDH who were appropriate candidates for discectomy, meeting all current indications. All patients were referred to the same spine surgeon (K.S.), and all procedures were performed at the Interbalkan European Medical Center in Thessaloniki, Greece. Patients were fully informed about the principles and aims of this study, and agreed to participate by providing informed written consent. The study was approved by the hospital's Medical Council and the local

Results

All patients successfully completed follow-up. Demographic characteristics of patients in the 2 groups are presented in Table 1. Baseline preoperative values of all SF-36 indices studied are provided in Table 2.

Preoperative evaluation showed that almost all of the parameters, including VAS-LP, VAS-BP, and SF-36 indices (except GH), were statistically significantly enhanced in group B compared with group A, despite the small differences in ultimate percentages between the 2 groups in the

Obesity and LBP

Obesity is a significant social health concern.1 Ogden et al.15 reported a 36.5% prevalence of obesity in US adults during 2011–2014. Numerous pathological conditions are associated with obesity, including diabetes, cardiovascular disorders, and osteoarthritis, demonstrating the multifaceted profile of this health condition.16

Obesity is defined by the World Health Organization as a BMI ≥30 kg/m2. Morbid obesity is defined as BMI ≥35 kg/m2 with 2 major comorbid conditions (e.g., diabetes,

Conclusions

Values of all evaluated indices were statistically significantly enhanced at 2 years postoperatively in the 2 groups, demonstrating the favorable outcomes of PTED in obese patients. However, the overwhelming majority of group A patients had lower scores at all follow-up intervals, demonstrating less clinical improvement, compared with the group B patients. PTED appears to be a generally safe and efficient technique for treating LDH in obese patients when performed by an experienced spine

References (31)

  • B.J. Pereira et al.

    Impact of body mass index in spinal surgery for degenerative lumbar spine disease

    Clin Neurol Neurosurg

    (2014)
  • G. Gkasdaris et al.

    Clinical anatomy and significance of the lumbar intervertebral foramen: a review

    J Anat Soc India

    (2015)
  • M.D. Castle-Kirszbaum et al.

    Obesity in neurosurgery: a narrative review of the literature

    World Neurosurg

    (2017)
  • A.M. Jakoi et al.

    The clinical correlations between diabetes, cigarette smoking and obesity on intervertebral degenerative disc disease of the lumbar spine

    Asian Spine J

    (2017)
  • J.S. Bae et al.

    Transforaminal full-endoscopic lumbar discectomy in obese patients

    Int J Spine Surg

    (2016)
  • Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults–The Evidence Report. National Institutes of Health

    Obes Res

    (1998)
  • T.A. Mirtz et al.

    Is obesity a risk factor for low back pain? An example of using the evidence to answer a clinical question

    Chiropr Osteopat

    (2005)
  • J.A. Rihn et al.

    The influence of obesity on the outcome of treatment of lumbar disc herniation: analysis of the Spine Patient Outcomes Research Trial (SPORT)

    J Bone Joint Surg Am

    (2013)
  • C.H. Flamme

    [Obesity and low back pain—biology, biomechanics and epidemiology]

    Orthopade

    (2005)
  • S. Kapetanakis et al.

    Health-related quality of life after transforaminal percutaneous endoscopic discectomy: an analysis according to the level of operation

    J Craniovertebr Junction Spine

    (2017)
  • Y.P. Wang et al.

    Evaluation of transforaminal endoscopic discectomy in treatment of obese patients with lumbar disc herniation

    Med Sci Monit

    (2016)
  • P. Kambin et al.

    Percutaneous posterolateral discectomy: anatomy and mechanism

    Clin Orthop Relat Res

    (1987)
  • S. Kapetanakis et al.

    Transforaminal percutaneous endoscopic discectomy for lumbar disc herniation in Parkinson's disease: a case-control study

    Asian Spine J

    (2016)
  • S. Kapetanakis et al.

    Transforaminal percutaneous endoscopic discectomy in Parkinson's disease: preliminary results and short review of the literature

    Korean J Spine

    (2016)
  • N.E. Epstein

    More risks and complications for elective spine surgery in morbidly obese patients

    Surg Neurol Int

    (2017)
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    Conflict of interest statement: Dr. Kapetanakis is a reference doctor for joimax GmbH and receives payments for teaching. The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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