Elsevier

World Neurosurgery

Volume 138, June 2020, Pages 19-26
World Neurosurgery

Literature Review
Minimum 2-Year Efficacy of Percutaneous Endoscopic Lumbar Discectomy versus Microendoscopic Discectomy: A Meta-Analysis

https://doi.org/10.1016/j.wneu.2020.02.096Get rights and content

Background

Minimally invasive surgery in the treatment of lumbar disc herniation has gained popularity in recent years, as 2 dominant techniques, percutaneous endoscopic lumbar discectomy (PELD) and microendoscopic discectomy (MED) obtained comparable short-term clinical outcomes. However, midterm and long-term efficacy and reoperative rate are still debated.

Methods

Electronic databases Web of Science, PubMed, Scopus, Cochrane Library, EMBASE, Ovid, and EBSCO were searched. STATA 14.0 was used for statistical analysis. Odds ratio (OR) and 95% confidence interval (CI) were pooled to quantify the strength of the statistical differences.

Results

Nine studies (468 patients in the PELD group and 516 patients in the MED group) with high methodologic quality met the selection criteria. No differences were found in leg pain visual analog scale score before surgery or at any follow-up time after surgery. PELD obtained better outcomes in low back pain visual analog scale score, Oswestry Disability Index score, and excellent and good ratio after 24 months postoperatively (OR = −0.856, 95% CI −1.488 to −0.224, P = 0.008; OR = −0.425, 95% CI −0.724 to −0.127, P = 0.005; OR = 3.034; 95% CI 1.254 to 7.343; P = 0.014) compared with MED. No difference was found within 24 months postoperatively. No significant differences were found in complication, recurrence, and reoperation rates within and after 2 years postoperatively.

Conclusions

Both PELD and MED can offer relatively effective and safe treatment for low back pain and radiculopathy associated with a herniated disc. PELD could obtain better midterm and long-term clinical outcomes compared with MED.

Introduction

Lumbar disc herniation (LDH) is one of the most common causes of low back pain (LBP) with or without pain and numbness of lower extremities. The previously reported incidence rate of LDH was 20%–35% among adults >50 years old.1, 2, 3 Although most patients with LDH achieved pain relief with conservative treatment such as physical therapy and pharmaceutical treatment, nearly 40%–60% of patients still need surgical intervention.4

With the concept of broad operative view, less trauma, and rapid recovery, microendoscopic discectomy (MED) was first described in 1997 by Smith and Foley5 and subsequently became widely used for the treatment of LDH via endoscopy and minimally invasive transmuscular approach.6,7 In recent years, percutaneous endoscopic lumbar discectomy (PELD) has become increasingly popular for the treatment of LDH. Previous studies have reported short-term clinical outcomes of PELD comparable to conventional surgical technique and MED, indicating this is an alternative technique for LBP and radicular pain based on its advantages of minimal invasiveness, local anesthesia, and rapid recovery.8, 9, 10, 11, 12 However, midterm and long-term efficacy and reoperative rate are still debated because of the relatively higher rate of early recurrence and steep learning curve of PELD.13, 14, 15, 16, 17, 18, 19, 20, 21 Moreover, no meta-analysis to our knowledge has evaluated the minimum 2-year efficacy of PELD and MED.17, 18, 19,22,23 Therefore, the aim of this study was to evaluate the midterm and long-term efficacy of PELD versus MED systematically and update the included studies to avoid being confounded by the different follow-up times to determine the superiority of PELD versus MED in the treatment of LDH.

Section snippets

Search Strategy

Nine articles were extracted by searching the electronic databases Web of Science, PubMed, Scopus, Cochrane Library, EMBASE, Ovid, and EBSCO. The search terms and commonly used synonyms and abbreviations were “percutaneous endoscopic lumbar discectomy/PELD” or “percutaneous transforaminal endoscopic discectomy/PTED” or “full-endoscopic interlaminar access/FEIL” or “full-endoscopic interlaminar approach/FEIA” or “percutaneous endoscopic interlaminar discectomy/PEID” or “full-endoscopic

Literature Search

A total of 487 studies were identified. We removed duplicate articles, which left 251 articles. We read the titles, abstracts, and full text of these articles, and 242 of them were ultimately excluded. Nine articles of high methodologic quality (≥6 NOS stars) were left that met the selection criteria with 468 patients in the PELD group and 516 patients in the MED group. A flow diagram of the literature search strategy is shown in Figure 1.

Quality Assessments and Baseline Characteristics

The NOS stars awarded to 9 studies are shown in Table 1,

Discussion

With the development of minimally invasive spine surgery, the safety and short-term effectiveness of PELD in the treatment of LBP and radiculopathy associated with a herniated disc has been confirmed.11,15,16,18,24 Our results indicated that both PELD and MED could obtain satisfactory midterm and long-term clinical efficacy; however, compared with MED, PELD could obtain better midterm and long-term LBP VAS score, ODI score, and excellent and good ratio.

Our results also suggested that PELD

Conclusions

As minimally invasive spine surgery techniques, both PELD and MED are effective and safe surgical treatments for LBP and radiculopathy associated with a herniated disc, with the advantages of less invasiveness, less destruction of stable structures, and quicker rehabilitation than traditional open discectomy. PELD could obtain better midterm and long-term clinical outcomes compared with MED.

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    Conflict of interest statement: 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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