Research ArticleEndoscopic Minimally Invasive Surgery

Differential Agnostic Effect Size Analysis of Lumbar Stenosis Surgeries

Kai-Uwe Lewandrowski, Ivo Abraham, Jorge Felipe Ramírez León, José Antonio Soriano Sánchez, Álvaro Dowling, Stefan Hellinger, Max Rogério Freitas Ramos, Paulo Sérgio Teixeira De Carvalho, Christopher Yeung, Nima Salari and Anthony Yeung
International Journal of Spine Surgery April 2022, 16 (2) 318-342; DOI: https://doi.org/10.14444/8222

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    Preferred reporting items for systematic reviews and meta-analyses flow chart of selected lumbar spinal stenosis studies found in PubMed, Embase, Web of Science, and in the Cochrane Central Register of Controlled Trials using the keywords “lumbar” and “herniated disc” or ‘‘spinal stenosis’’ and ‘‘endoscopic” and ‘‘ODI” and ‘‘VAS” as subject headings analyzed to compare effect sizes of endoscopic to traditional translaminar decompression with and without fusion. ODI, Oswestry Disability Index; VAS, visual analog scale.

  • Figure 2
    Figure 2

    Meta-analysis regression plot of effect size (ES) vs standard error stratified for the type of decompression surgery using random effects model showed substantial overlap in the plotted relationship between these procedures and, hence, clinical benefit with all lumbar decompression methods some of which were with fusion including endoscopy with statistical significance in spite of the underlying risk of moderate publication bias: endoscopic-assisted minimally invasive surgery fusion - 3 studies, ES = 0.94, endoscopy - 84 studies, ES = 0.9, open laminectomy - 6 studies, ES = 0.89, and tubular microdiscectomy - 21 studies, ES = 0.89, P = 0.022.

  • Figure 3
    Figure 3

    Meta-analysis area plot of effect size (ES) vs standard error using random effects model showed substantial overlap in the plotted relationship between these 2 variables and, hence, clinical benefit with all endoscopic lumbar decompression methods in spite of the underlying risk of moderate publication bias: transforaminal outside-in with combined interlaminar approach - 1 study, ES = 0.97, uniportal biportal endoscopy (UBE) - 6 studies, ES = 0.92, interlaminar approach - 23 studies, ES = 0.93, transforaminal inside-out approach - 2 studies, ES = 0.89, and transforaminal outside-in approach - 54 studies, ES = 0.89, with statistically significant ES differences between these procedures (P < 0.001).

  • Figure 4
    Figure 4

    Forest plot of effect sizes (ESs), 95% CI, and the number of patients enrolled in each individual endoscopic spinal surgery study (N) calculated for the 46 study groups which reported Oswestry Disability Index with a minimum of 2 y or longer follow-up listed in alphabetical order according to the first author’s name. The number of individual study patients is represented by the size of the symbol. The overall ES was 0.92 with a lower 95% CI limit of 0.9, and an upper limit of 0.94 calculated from the total of 9420 patient samples enrolled in these studies.

  • Figure 5
    Figure 5

    Forest plot of effect sizes (ESs), 95% CI, and the number of patients enrolled in each individual endoscopic spinal surgery study (N) calculated for the 26 study groups which reported visual analog scale back with a minimum of 2 y or longer follow-up listed in alphabetical order according to the first author’s name. The number of individual study patients is represented by the size of the symbol. The overall ES was 0.71 with a lower 95% CI limit of 0.61, and an upper limit of 0.81 calculated from the total of 4926 patient samples enrolled in these studies.

  • Figure 6
    Figure 6

    Forest plot of effect sizes (ESs), 95% CI, and the number of patients enrolled in each individual endoscopic spinal surgery study (N) calculated for the 44 study groups which reported visual analog scale leg with a minimum of 2 y or longer follow-up listed in alphabetical order according to the first author’s name. The number of individual study patients is represented by the size of the symbol. The overall ES was 0.89 with a lower 95% CI limit of 0.86, and an upper limit of 0.92 calculated from the total of 8806 patients enrolled in these studies.

Tables

  • Table 1

    List of short-term (<2-year follow-up) lumbar decompression studies included into the effect size meta-analysis comparing endoscopic to other translaminar decompression surgeries with brief summary of study highlights.

    #AuthorsYearTitleReferenceStudy Highlights
    1.Abudurexiti T, Qi L, et al36 2018Microendoscopic discectomy vs percutaneous endoscopic surgery for lumbar disk herniation.J Int Med Res 2018;46:3910–7.Prospective study comparing PELD vs MED in the treatment of 216 patients with lumbar disc herniation
    2.Ahn JS, Lee HJ, et al78 2018Extraforaminal approach of biportal endoscopic spinal surgery: a new endoscopic technique for transforaminal decompression and discectomy.J Neurosurg Spine 2018;28:492–8.Retrospective cohort study of 21 patients treated with biportal endoscopic spinal surgery as a new endoscopic technique for transforaminal decompression
    3.Ao S, Wu J, et al19 2019Percutaneous endoscopic lumbar discectomy assisted by O-arm-based navigation improves the learning curve.Biomed Res Int 2019;2019:6509409.Prospective cohort study of 118 patients to assess the safety and efficacy of PELD assisted by O-arm-based navigation for treating LDH
    4.Cao S, Cui H, et al138 2019"Tube in tube" interlaminar endoscopic decompression for the treatment of lumbar spinal stenosis: technique notes and preliminary clinical outcomes of case series.Medicine (Baltimore) 2019;98:e17021.Retrospective efficacy and safety study of 35 patients treated with tube-in-tube interlaminar endoscopic MED decompression in treating LSS
    5.Chen Z, Zhang L, et al114 2018Percutaneous transforaminal endoscopic discectomy compared with microendoscopic discectomy for lumbar disc herniation: 1 year results of an ongoing randomized controlled trial.J Neurosurg Spine 2018;28:300–10.Randomized prospective controlled study of 153 patients to investigate whether percutaneous transforaminal endoscopic discectomy results in better clinical outcomes and less surgical trauma than MED
    6.Choi G, Lee SH, et al139 2006Percutaneous endoscopic interlaminar discectomy for intracanalicular disc herniations at L5-S1 using a rigid working channel endoscope.Neurosurgery 2006;58:ONS59-68; discussion ONS59-68.Retrospective study of 65 patientson the procedure and clinical results of interlaminar L5-S1 level PELD and the relevant surgical anatomy
    7.Dabo X, Ziqiang C, et al24 2016The clinical results of percutaneous endoscopic interlaminar discectomy (PEID) in the treatment of calcified lumbar disc herniation: a case-control study.Pain Physician 2016;19:69–76.Retrospective case-control study of 30 patients treated with PELD for calcified and noncalcified lumbar disc herniations
    8.Eun SS, Chachan S, et al140 2018Interlaminar percutaneous endoscopic lumbar discectomy: rotate and retract technique.World Neurosurg 2018;118:188–92.Retrospective study of 17 patients who underwent interlaminar PELD with the rotate and retract technique
    9.Eun SS, Eum JH, et al112 2017Biportal endoscopic lumbar decompression for lumbar disk herniation and spinal canal stenosis: a technical note.J Neurol Surg A Cent Eur Neurosurg 2017;78:390–6.Retrospective study of 17 patients treated with biportal endoscopic lumbar decompression technique using 2 portals to treat difficult lumbar disc herniations and also lumbar spinal stenoses
    10Gadjradj, Pravesh S, et al141 2016Clinical outcomes after percutaneous transforaminal endoscopic discectomy for lumbar disc herniation: a prospective case series.Neurosurg Focus. 2016 Feb;40(2):E3.Prospective study of 166 patients who underwent surgery for a total of 167 LDH
    11.He S, Sun Z, et al26 2018Combining YESS and TESSYS techniques during percutaneous transforaminal endoscopic discectomy for multilevel lumbar disc herniation.Medicine (Baltimore) 2018;97:e11240.Retrospective study on 52 patients with multilevel LDH treated with combination of YESS and TESSYS
    12.Heo DH, Lee DC, et al113 2019Comparative analysis of three types of minimally invasive decompressive surgery for lumbar central stenosis: biportal endoscopy, uniportal endoscopy, and microsurgery.Neurosurg Focus 2019;46:E9.Retrospective study on MED vs endoscopic unilateral laminotomy with bilateral decompression to treat lumbar canal stenosis
    13.Heo DH, Sharma S, et al66 2019Endoscopic treatment of extraforaminal entrapment of L5 nerve root (far out syndrome) by unilateral biportal endoscopic approach: technical report and preliminary clinical results.Neurospine 2019;16:130–7.Retrospective consecutive of 16 patients with unilateral extraforaminal entrapment of the L5 nerve root (far out syndrome) treated with percutaneous biportal endoscopies
    14.Hsu HT, Chang SJ, et al142 2013Learning curve of full-endoscopic lumbar discectomy.Eur Spine J 2013;22:727–33.Retrospective study of 57 patients who underwent full-endoscopic lumbar discectomy and 66 patients who underwent open microdiscectomy
    15.Hu A, Gu X, et al5 2018Epidural vs intravenous steroids application following percutaneous endoscopic lumbar discectomy.Medicine (Baltimore) 2018;97:e0654.Retrospective study of LDH patients who had undergone transforaminal PELD comparing epidural steroid, intravenous steroid to control a group each containing 60 patients
    16.Hu Z, Li X, et al45 2017Significance of preoperative planning software for puncture and channel establishment in percutaneous endoscopic lumbar discectomy: a study of 40 cases.Int J Surg 2017;41:97–103.Retrospective study of 40 patients to compare the clinical efficacy of preoperative planning software in puncture and channel establishment of PELD
    17.Hua W, Tu J, et al13 2018Full-endoscopic discectomy via the interlaminar approach for disc herniation at L4-L5 and L5-S1: an observational study.Medicine (Baltimore) 2018;97:e0585.Retrospective study of 80 patients to investigate the clinical outcomes of full-endoscopic discectomy via the interlaminar approach for LDH at L4-L5 under general anesthesia
    18.Hua W, Zhang Y, et al7 2018Outcomes of discectomy by using full-endoscopic visualization technique via the interlaminar and transforaminal approaches in the treatment of L5-S1 disc herniation: an observational study.Medicine (Baltimore) 2018;97:e13456.Retrospective study of 60 patients treated with full-endoscopic visualization technique via the interlaminar approach vs the transforaminal approach for LDH under general anesthesia
    19.Hubbe U, Franco-Jimenez P, et al143 2006Minimally invasive tubular microdiscectomy for recurrent lumbar disc herniation.J Neurosurg Spine 2016;24:48–53.Retrospective safety and efficacy of minimally invasive tubular microdiscectomy LDH
    20.Hwa Eum J, Hwa Heo D, et al74 2016Percutaneous biportal endoscopic decompression for lumbar spinal stenosis: a technical note and preliminary clinical results.J Neurosurg Spine 2016;24:602–7.Retrospective study of 58 single-level lumbar stenosis patients who underwent unilateral laminotomy with bilateral foraminal decompression using a unilateral biportal endoscopic system
    21.Kapetanakis S, Giovannopoulou E, et al144 2016Transforaminal percutaneous endoscopic discectomy in Parkinson disease: preliminary results and short review of the literature.Korean J Spine 2016;13:144–50.Retrospective case-control effectiveness study of transforaminal PELD in 10 Parkinson patients and 10 control patients
    22.Kim HS, Adsul N, et al145 2018Full-endoscopic lumbar discectomy using the calcification floating technique for symptomatic partially calcified lumbar herniated nucleus pulposus.World Neurosurg 2018;119:500–5.Retrospective study of 31 patients who underwent full-endoscopic discectomy using free floating technique for partially calcified lumbar HNP
    23.Kim HS, Adsul N, et al1 2018A mobile outside-in technique of transforaminal lumbar endoscopy for lumbar disc herniations.J Vis Exp 2018.Prospective study of 184 patients to describe the technical aspects of a novel mobile outside-in method in dealing with different types of disc prolapse
    24.Kim HS, Paudel B, et al56 2018Percutaneous endoscopic lumbar discectomy for all types of lumbar disc herniations (LDH) including severely difficult and extremely difficult LDH cases.Pain Physician 2018;21:E401-E8.Retrospective consecutive case study of 98 patients who underwent PELD for severely difficult and extremely difficult
    25.Kim HS, Yudoyono F, et al68 2017Analysis of clinical results of three different routes of percutaneous endoscopic transforaminal lumbar discectomy for lumbar herniated disk.World Neurosurg 2017;103:442–8.Retrospective study of 71 transforaminal PELD patients divided in the foraminal (group A), intervertebral (group B), and suprapedicular (group C) with 32, 46, and 33 patients, respectively
    26.Li LJ, Chang F, et al146 2018Clinical effects of percutaneous endoscopic transforaminal decompression for the treatment of lumbar spinal stenosis.Zhongguo Gu Shang 2018;31:617–20.Retrospective study of 67 patients who underwent transforaminal PELD for lumbar spinal stenosis
    27.Li M, Yang H, et al27 2015Full-endoscopic technique discectomy vs microendoscopic discectomy for the surgical treatment of lumbar disc herniation.Pain Physician 2015;18:359–63.Restrospective study of 85 patients treated with PELD vs MED for LDH
    28.Li XF, Jin LY, et al147 2019Endoscopic ventral decompression for spinal stenosis with degenerative spondylolisthesis by partially removing posterosuperior margin underneath the slipping vertebral body: technical note and outcome evaluation.World Neurosurg 2019;126:e517-e25.Retrospective study of 25 patients to describe the percutaneous transforaminal endoscopic ventral decompression technique
    29.Liu W, Li Q, et al4 2019Clinical efficacy of percutaneous transforaminal endoscopic discectomy in treating adolescent lumbar disc herniation.Medicine (Baltimore) 2019;98:e14682.Retrospective study of 43 adolescent patients diagnosed with single-segment LDH treated with transforaminal PELD
    30.Liu X, Yuan S, et al111 2018Comparison of percutaneous endoscopic transforaminal discectomy, microendoscopic discectomy, and microdiscectomy for symptomatic lumbar disc herniation: minimum 2 year follow-up results.J Neurosurg Spine 2018;28:317–25.Retrospective study of 192 LDH patients at L3-L4 and L4-L5 divided into PELD (60 patients), MED (63 patients), and microdiscectomy (69 patients)
    31.Liu Y, Cai P, et al148 2017Effectiveness of percutaneous endoscopic spine surgery for treatment of lumbar spine disorders with intraspinal ossification.Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2017;31:1326–33.Retrospective study of 96 patients with LDH and LSS with intraspinal ossification were treated with PELD
    32.Madhavan K, Chieng LO, et al149 2016Early experience with endoscopic foraminotomy in patients with moderate degenerative deformity.Neurosurg Focus 2016;40:E6.Retrospective study of retrospective analysis of 16 patients with coronal deformity of between 10° and 20° treated with PELD
    33.Pan Z, Ha Y, et al42 2016Efficacy of transforaminal endoscopic spine system (TESSYS) technique in treating lumbar disc herniation.Med Sci Monit 2016;22:530–9.Retrospective study efficacy and safety study in 109 patients treated with percutaneous TESSYS and traditional fenestration discectomy
    34.Sang PM, Zhang M, et al150 2018Treatment of migrated lumbar disc herniation with percutaneous endoscopic lumbar discectomy and target foraminoplasty.Zhongguo Gu Shang 2018;31:302–5.Retrospective study of 25 patients with migrated LDH were treated with PELD with target foraminoplasty
    35.Shi C, Kong W, et al9 2018The early clinical outcomes of a percutaneous full-endoscopic interlaminar approach via a surrounding nerve root discectomy operative route for the treatment of ventral-type lumbar disc herniation.Biomed Res Int 2018;2018:9157089.Retrospective study of 22 patients undergoing full-endoscopic interlaminar discectomy for ventral LDH via both the shoulder and the axilla of the corresponding nerve root
    36.Shin SH, Bae JS, et al151 2018Transforaminal endoscopic decompression for lumbar spinal stenosis: a novel surgical technique and clinical outcomes.World Neurosurg 2018;114:e873-e82.Retrospective study of 30 consecutive cases LCS treated with transforaminal endoscopic decompression
    37.Sun Y, Zhang W, et al38 2017Comprehensive comparing percutaneous endoscopic lumbar discectomy with posterior lumbar internal fixation for treatment of adjacent segment lumbar disc prolapse with stable retrolisthesis: a retrospective case-control study.Medicine (Baltimore) 2017;96:e7471.Retrospective comparison study PELD (11 patients) and PLIF (13 patients) for treatment of adjacent segment lumbar disc prolapse with stable retrolisthesis after a previous fusion
    38.Tang S, Jin S, et al25 2018Transforaminal percutaneous endoscopic lumbar decompression by using rigid bendable burr for lumbar lateral recess stenosis: technique and clinical outcome.Biomed Res Int 2018;2018:2601232.Retrospective comparative study PELD open decompression in LSS in 48 consecutive patients
    39.Tao, X. Z., Jing, L, et al20 2018Therapeutic effect of transforaminal endoscopic spine system in the treatment of prolapse of lumbar intervertebral disc.Eur Rev Med Pharmacol Sci. 2018 Jul;22(1 Suppl):103–110.Randomized prospective trial of 462 LDH patients treated with PELD (n = 231) and open decompression in the control group (n = 231)
    40.Wang H, Zhou Y, et al18 2015Risk factors for failure of single-level percutaneous endoscopic lumbar discectomy.J Neurosurg Spine 2015;23:320–5.Retrospective study to identify risk factors for failure of PELD for single-level LDH in 350 patients who underwent PELD
    41.Wang J, Zhou Y, et al152 2009Percutaneous endoscopic lumbar discectomy for treatment of chronic discogenic low back pain.Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2009;23:400–3.Retrospective study of 52 PELD patients with discogenic chronic low back pain
    42.Wang SJ, Chen BH, et al23 2017The effect of percutaneous endoscopic lumbar discectomy under different anesthesia on pain and immunity of patients with prolapse of lumbar intervertebral disc.Eur Rev Med Pharmacol Sci 2017;21:2793–9.Restrospective study of 82 PELD patients under different anesthesia on pain and immunity of patients with lumbar disc herniation
    43.Wang Y, Yan Y, et al153 2019Outcomes of percutaneous endoscopic transarticular discectomy for huge central or paracentral lumbar disc herniation.Int Orthop 2019;43:939–45.Retrospective study on 16 patients undergoing percutaneous endoscopic transarticular discectomy for huge central/paracentral LDH
    44.Wen B, Zhang X, et al43 2016Percutaneous endoscopic transforaminal lumbar spinal canal decompression for lumbar spinal stenosis.Medicine (Baltimore) 2016;95:e5186.Retrospective study of 64 patients with lumbar spinal stenosis who underwent percutaneous endoscopic lumbar spinal canal decompression
    45.Wu GN, Zhang SM, et al154 2017Percataneous endoscopic lumbar discectomy for the treatment of lumbar intervertebral disc protrusion.Zhongguo Gu Shang 2017;30:861–5.Retrospective study of 46 PELD patients treated for LDH.
    46.Xin Z, Huang P, et al51 2019Using a percutaneous spinal endoscopy unilateral posterior interlaminar approach to perform bilateral decompression for patients with lumbar lateral recess stenosis.Asian J Surg 2019.Retrospective study of 47 patients with bilateral symptomatic LCS treated with percutaneous spinal endoscopy via a unilateral posterior interlaminar approach with bilateral decompression
    47.Xiong C, Li T, et al116 2009Early outcomes of 270 degree spinal canal decompression by using TESSYS-ISEE technique in patients with lumbar spinal stenosis combined with disk herniation.Eur Spine J 2019;28:78–86.Retrospective study of 32 patients with LSS due to LDH with newly developed minimal invasive TESSYS-ISEE technique
    48.Xu B, Xu H, et al11 2017Anatomic investigation of lumbar transforaminal fenestration approach and its clinical application in far lateral disc herniation.Medicine (Baltimore) 2017;96:e7542.Retrospective study of 30 patients with LDH underwent MED via the transforaminal fenestration approach
    49.Xu Z, Liu Y, et al28 2018Percutaneous ndoscopic interlaminar discectomy for L5-S1 adolescent lumbar disc herniation.Turk Neurosurg 2018;28:923–8.Retrospective study of 23 adolescent patients who underwent percutaneous endoscopic interlaminar discectomy for L5-S1 LDH
    50.Yang D, Wu X, et al155 2018A modified percutaneous endoscopic technique to remove extraforaminal disk herniation at the L5-S1 segment.World Neurosurg 2018;119:e671-e8.Retrospective study of 100 extraforaminal LDH patients. The geometric parameters of the transverse process, facet joint, and sacrum space based on imaging examination were measured
    51.Yang JC, Hai Y, et al156 2018Percutaneous endoscopic transforaminal lumbar interbody fusion for lumbar spinal stenosis.Zhonghua Yi Xue Za Zhi 2018;98:3711–5.Retrospective study of percutaneous endoscopic transforaminal lumbar interbody fusion in 7 patients with L4-L5 single-segment lumbar spinal stenosis
    52.Ying J, Huang K, et al40 2016The effect and feasibility study of transforaminal percutaneous endoscopic lumbar discectomy via superior border of inferior pedicle approach for down-migrated intracanal disc herniations.Medicine (Baltimore) 2016;95:e2899.Retrospective study of 45 PELD patients with down-migrated single-level LDH treated with upper border of inferior pedicle, foraminoplasty, or common transforaminal route
    53.Zhang J, Jin MR, et al185 2019Clinical application of percutaneous transforaminal endoscope-assisted lumbar interbody fusion.Zhongguo Gu Shang 2019;32:1138–43.Retrospective safety and efficacy study on 25 patients percutaneous transforaminal endoscope-assisted lumbar interbody fusion

    • HNP, Herniated Nucleus Pulposus; ISEE, Interlaminar Endoscopy; LCS, lateral canal stenosis; LDH, lumbar disc herniation; LSS, lumbar spinal stenosis; MED, minimally endoscopic discectomy; PELD, percutaneous endoscopic lumbar discectomy; TESSYS, transforaminal endoscopic spine system; YESS, Yeung endoscopic spine system.

  • Table 2

    List of long-term (>2-year follow-up) lumbar stenosis decompression studies included into the effect size meta-analysis comparing endoscopic to other translaminar decompression surgeries with brief summary of study highlights.

    #AuthorsYearTitleReferenceStudy Highlights
    1.Ahn Y, Keum HJ, et al157 2019Transforaminal endoscopic decompression for lumbar lateral recess stenosis: an advanced surgical technique and clinical outcomes.World Neurosurg 2019;125:e916-e24.Retrospective study of 45 consecutive patients who underwent transforaminal endoscopic decompression for LCS.
    2.Ahn Y, Lee HY, et al158 2011Dural tears in percutaneous endoscopic lumbar discectomy.Eur Spine J 2011;20:58–64.Retrospective study of 816 consecutive PELD patients to assess frequency of dural tears.
    3.Ahn Y, Lee SG, et al75 2009Transforaminal endoscopic lumbar discectomy vs open lumbar microdiscectomy: a comparative cohort study with a 5 year follow-up.Pain Physician 2019;22:295–304.Prospective study of 335 LDH patients treated with PELD or open lumbar microdiscectomy.
    4.Ahn Y, Lee U, et al71 2018Five-year outcomes and predictive factors of transforaminal full-endoscopic lumbar discectomy.Medicine (Baltimore) 2018;97:e13454.Retrospective 5-y outcomes study of 204 transforaminal PELD patients to determine the factors predicting favorable outcome.
    5.Bai YB, Xu L, et al159 2012Diagnosis and treatment of lumbar disc herniation by discography and percutaneous transforaminal endoscopic surgery.Zhonghua Yi Xue Za Zhi 2012;92:3350–3.Retrospective study of 119 patients with lumbar disc herniation who underwent discography and transforaminal endoscopic surgery under local anesthesia.
    6.Casal-Moro R, Castro-Menendez M, et al160 2011Long-term outcome after microendoscopic diskectomy for lumbar disk herniation: a prospective clinical study with a 5 year follow-up.Neurosurgery 2011;68:1568–75; discussion 75.Prospective study of 120 LDH patients treated with MED using an 18-mm METRxtubular retractor.
    7.Choi G, Lee SH, et al161 2007Percutaneous endoscopic discectomy for extraforaminal lumbar disc herniations: extraforaminal targeted fragmentectomy technique using working channel endoscope.Spine (Phila Pa 1976) 2007;32:E93-9.Retrospective analysis of 41 patients with soft lumbar extraforaminal disc herniation treated with PELD.
    8.Choi G, Modi HN, et al162 2013Clinical results of XMR-assisted percutaneous transforaminal endoscopic lumbar discectomy.J Orthop Surg Res 2013;8:14.Prospective study of 89 LDH patients who had undergone PELD.
    9.Choi KC, Kim JS, et al163 2016Percutaneous endoscopic lumbar discectomy as an alternative to open lumbar microdiscectomy for large lumbar disc herniation.Pain Physician 2016;19:E291-300.Retrospective study of 30 consecutive patients treated with transforaminal and interlaminar PELD for L5- S1 disc herniation.
    10.Choi KC, Park CK76 2016Percutaneous endoscopic lumbar discectomy for L5-S1 disc herniation: consideration of the relation between the Iliac crest and L5-S1 disc.Pain Physician 2016;19:E301-8.Retrospective study of 100 consecutive L5-S1 PELD patients with and without foraminoplasty.
    11.Chung J, Kong C, et al164 2019Percutaneous endoscopic lumbar foraminoplasty for lumbar foraminal stenosis of elderly patients with unilateral radiculopathy: radiographic changes in magnetic resonance images.J Neurol Surg A Cent Eur Neurosurg 2019;80:302–11.Retrospective study of 24 patients aged >65 y underwent PELD to treat unilateral radiculopathy caused by LCS.
    12.Dey PC, Nanda SN60 2019Functional outcome after endoscopic lumbar discectomy by Destandau’s technique: a prospective study of 614 patients.Asian Spine J 2019;13:786–92.Prospective study of 614 LDH patients treated with PELD.
    13.Eun SS, Lee SH, et al165 2018Transforaminal percutaneous endoscopic lumbar diskectomy for down-migrated disk herniations: lever-up, rotate, and tilt technique.J Neurol Surg A Cent Eur Neurosurg 2018;79:163–8.Retrospective review of 18 LDH patients who underwent PELD.
    14.Gibson JNA, Subramanian AS, et al166 2017A randomised controlled trial of transforaminal endoscopic discectomy vs microdiscectomy.Eur Spine J 2017;26:847–56.Randomized prospective study of 143 single-level LDH patients: 70 received TED under conscious sedation and 70 MED under general anesthesia.
    15.Hong X, Shi R, et al167 2018Lumbar disc herniation treated by microendoscopic discectomy: prognostic predictors of long-term postoperative outcome.Orthopade 2018;47:993–1002.Retrospective study of 664 LDH patients who suffered from sciatica and underwent primary MED.
    16.Kim JE, Choi DJ55 2018Clinical and radiological outcomes of unilateral biportal endoscopic decompression by 30 degrees arthroscopy in lumbar spinal stenosis: minimum 2 year follow-up.Clin Orthop Surg 2018;10:328–36.Retrospective study of 55 LSS patients treated with PELD.
    17.Kim JE, Choi DJ67 2018Unilateral biportal endoscopic decompression by 30 degrees endoscopy in lumbar spinal stenosis: technical note and preliminary report.J Orthop 2018;15:366–71.Retrospective study of 105 patients receiving 30° endoscopy through biportals or triportals.
    18.Komp M, Hahn P, et al97 2015Bilateral spinal decompression of lumbar central stenosis with the full-endoscopic interlaminar vs microsurgical laminotomy technique: a prospective, randomized, controlled studyPain Physician. 2015 Jan-Feb;18(1):61–70.Randomized prospective study of 135 patients comparing FEID with a conventional microsurgical laminotomy technique.
    19.Kong W, Chen T, et al41 2019Treatment of L5-S1 intervertebral disc herniation with posterior percutaneous full-endoscopic discectomy by grafting tubes at various positions via an interlaminar approach.BMC Surg 2019;19:124.Retrospective study on 98 patients with L5-S1 LDH were treated with PELD.
    20.Lee SH, Kang HS, et al168 2010Foraminoplastic ventral epidural approach for removal of extruded herniated fragment at the L5-S1 level.Neurol Med Chir (Tokyo) 2010;50:1074–8.Retrospective review was performed of 25 consecutive LDH patients treated with PELD with foraminoplasty.
    21.Lewandrowski KU, Ostergren M, et al169 2018Intradiscal expandable balloon distraction during transforaminal decompression for lumbar foraminal and lateral recess stenosis.Surg Innov 2018;25:165–73.Retrospective study of 52 patients with symptomatic LCS treated with PELD.
    22.Li H, Jiang C, et al52 2018Comparison of MED and PELD in the treatment of adolescent lumbar disc herniation: a 5 year retrospective follow-up.World Neurosurg 2018;112:e255-e60.Retrospective efficacy and safety study MED and PELD in the treatment of 30 ALDH patients.
    23.Li ZZ, Hou SX, et al30 2017Modified percutaneous lumbar foraminoplasty and percutaneous endoscopic lumbar discectomy: instrument design, technique notes, and 5 years follow-up.Pain Physician 2017;20:E85-E98.Prospective cohort study of 148 patients with uncontained LDH was treated with modified percutaneous lumbar foraminoplasty PELD.
    24.Lubbers, T.Abuamona, R., et al170 2012Percutaneous endoscopic treatment of foraminal and extraforaminal disc herniation at the L5-S1 level.Acta Neurochir (Wien). 2012 Oct;154(10):1789–95.Prospective study of 22 PELD patients with lateral and far lateral LDH at the L5-S1.
    25.Pan F, Shen B, et al49 2016Transforaminal endoscopic system technique for discogenic low back pain: a prospective cohort study.Int J Surg 2016;35:134–8.Retrospective study 77 consecutive patients treated with PELD for discogenic low back pain.
    26.Shawky Abdelgawaad A, Babic D, et al171 2018Extraforaminal microscopic-assisted percutaneous nucleotomy for foraminal and extraforaminal lumbar disc herniations.Spine J 2018;18:620–5.Prospective cohort study of 76 patients with foraminal or extraforaminal LDH treated with tubular percutaneous extraforaminal microscopic-assisted nucleotomy.
    27.Soliman HM172 2013Irrigation endoscopic discectomy: a novel percutaneous approach for lumbar disc prolapse.Eur Spine J 2013;22:1037–44.Prospective of 43 patients with uncontained LDH underwent surgery biportal with irrigation endoscopic discectomy.
    28.Song H, Hu W, et al46 2017Percutaneous endoscopic interlaminar discectomy of L5-S1 disc herniation: a comparison between intermittent endoscopy technique and full endoscopy technique.J Orthop Surg Res 2017;12:162.Retrospective study of 126 patients intermittent endoscopy technique and full endoscopy technique of endoscopic interlaminar lumbar discectomy at the L5-S1.
    29.Teli M, Lovi A, et al173 2010Higher risk of dural tears and recurrent herniation with lumbar microendoscopic discectomy.Eur Spine J 2010;19:443–50.Randomized controlled trial of 240 patients was randomized to microendoscopic (group 1), micro (group 2) or open (group 3) discectomy with minimum 2-y follow-up.
    30.Tu Z, Wang B, et al53 2018Early experience of full-endoscopic interlaminar discectomy for adolescent lumbar disc herniation with sciatic scoliosis.Pain Physician 2018;21:E63-E70.Retrospective case series of patients aged < 20 y with single-level ALDH with and without scoliosis treated withFEID; average follow-up 39.0 mo.
    31.Wang Y, Zhang W, et al10 2018Transforaminal endoscopic discectomy for treatment of central disc herniation: surgical techniques and clinical outcome.Pain Physician 2018;21:E113-E23.Retrospective 2-y follow-up study of 69 consecutive patients treated with transforaminal PELD central disc herniation.
    32.Wang YP, Zhang W, et al33 2016Suprapedicular foraminal endoscopic approach to lumbar lateral recess decompression surgery to treat degenerative lumbar spinal stenosis.Med Sci Monit 2016;22:4604–11.Retrospective study of 52 patients with lumbar spinal stenosis underwent transforaminal endoscopic surgery.
    33.Xu B, Xu H, et al174 2018Bilateral decompression and intervertebral fusion via unilateral fenestration for complex lumbar spinal stenosis with a mobile microendoscopic technique.Medicine (Baltimore) 2018;97:e9715.Retrospective study on 61 patients with complex lumbar spinal stenosis (lumbar canal stenosis combined with degenerative spondylolisthesis, instability, and scoliosis) treated with Destandau-type mobile microendoscopic discectomy
    34.Youn MS, Shin JK, et al64 2018Endoscopic posterior decompression under local anesthesia for degenerative lumbar spinal stenosis.J Neurosurg Spine 2018;29:661–6.Retrospective study of 50 patients (28 women and 22 men) treated for LDH with endoscopic posterior decompression under local anesthesia followed up to 24 mo postoperatively.
    35.Zhang B, Kong Q, et al175 2019Short-term effectiveness of percutaneous endoscopic transforaminal bilateral decompression for severe central lumbar spinal stenosis.Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2019;33:1399–405.Retrospective study on effectiveness and safety of bilateral transforaminal bilateral PELD decompression for severe central lumbar spinal stenosis in 44 patients.
    36.Zhang Y, Chong F, et al17 2019Comparison of endoscope-assisted and microscope-assisted tubular surgery for lumbar laminectomies and discectomies: minimum 2 year follow-up results.Biomed Res Int 2019;2019:5321580.Retrospective study of 307 withLumbar spinal stenosis or LDH treated with endoscope- or microscope-assisted tubular laminectomy or discectomy.

    • ALDH, adolescent lumbar disc herniation; FEID, full-endoscopic interlaminar discectomy; LCS, lateral canal stenosis; LDH, lumbar disc herniation; LSS, lumbar spinal stenosis; MED, minimally endoscopic discectomy; METRx, minimal exposure tubular retractor; PELD, percutaneous endoscopic lumbar discectomy; TED, transforaminal endoscopic discectomy.

  • Table 3

    Analysis of effect size, heterogeneity, and ANOVA testing of difference by study type.

    Study DesignNumber of Studies Included in this AnalysisEffect SizeLower LimitUpper LimitHiggins I 2 Statistic of HeterogeneityVarianceStandard ErrorNumber of Patients
    Oswestry Disability IndexProspective study60.92170.86440.97890.00000.00090.02922106
    Randomized prospective study110.91000.83980.98020.00000.00130.03581891
    Retrospective study830.92340.90950.93730.00000.00010.007112,464
    ANOVA Q test random effects with separate estimates of T 2 Sig = 0.925Total patient samples16,461
    VAS backProspective study30.59510.30930.88090.00000.02130.1458534
    Randomized prospective study390.80090.74120.86060.00000.00090.03056056
    Retrospective study50.80590.72360.88820.00000.00180.0420670
    ANOVA Q test random effects with separate estimates of T 2 Sig = 0.204Total patient samples7260
    VAS legProspective study70.93180.87740.98620.00000.00080.02782258
    Randomized prospective study70.88340.80660.96030.00000.00150.03921594
    Retrospective study820.91340.89800.92880.00000.00010.007911,701
    ANOVA Q test random effects with separate estimates of T 2 Sig = 0.575Total patient samples15,553

    • ANOVA, analysis of variance; Sig, significance level of 95% CI; VAS, visual analog scale.

  • Table 4

    Analysis of effect size, heterogeneity, and ANOVA testing of difference by surgery indication.

    Indication for SurgeryNumber of Studies Included in This AnalysisEffect SizeLower LimitUpper LimitHiggins I 2 Statistic of HeterogeneityVarianceStandard ErrorNumber of Patients
    Oswestry Disability IndexDiscogenic pain20.91120.88660.93590.00000.00020.0126216
    HNP radiculopathy220.91790.88880.94710.00000.00020.01493520
    Stenosis claudication140.95310.92900.97720.00000.00020.01231638
    ANOVA Q test random effects with separate estimates of T 2 Sig = 0.094Total patient samples5374
    VAS backStenosis claudication50.87450.77920.96980.00000.00240.0486388
    HNP radiculopathy100.70860.55220.86500.00000.00640.07981108
    ANOVA Q test random effects with separate estimates of T 2 Sig = 0.074Total patient samples1496
    VAS legStenosis claudication130.91130.86730.95530.00000.00050.02251024
    HNP radiculopathy230.89420.86120.92730.00000.00030.01693667
    Discogenic pain30.88280.82040.94520.00000.00100.0318320
    ANOVA Q test random effects with separate estimates of T 2 Sig = 0.74Total patient samples5011

    • ANOVA, analysis of variance; HNP, herniated nucleus pulposus; Sig, significance level of 95% CI; VAS, visual analog scale.

  • Table 5

    Analysis of effect size, heterogeneity, and ANOVA testing of difference by length of follow-up.

    Length of Follow-UpNumber of Studies Included in This AnalysisEffect SizeLower LimitUpper LimitHiggins I 2 Statistic of HeterogeneityVarianceStandard ErrorNumber of Patients
    Oswestry Disability IndexMore than 2 y450.92430.90440.94420.00000.00010.01019304
    Up to 2 y460.92400.89960.94840.00000.00020.01255283
    Up to 12 mo150.90740.87750.93720.00000.00020.01522664
    Up to 6 mo20.91040.88620.93450.00000.00020.0123292
    ANOVA Q test random effects with separate estimates of T 2 Sig = 0.678Total patient samples17,543
    VAS backMore than 2 y250.70750.60430.81060.00000.00280.05264948
    Up to 2 y210.90230.87230.93230.00000.00020.01531978
    Up to 12 mo60.70070.59100.81040.00000.00310.0560872
    ANOVA Q est random effects with separate estimates of T 2 Sig <0.0001Total patient samples7798
    VAS legMore than 2 y430.89200.86510.91900.00000.00020.01388690
    Up to 2 y460.94410.92990.95820.00000.00010.00725237
    Up to 12 mo160.89150.84650.93650.00000.00050.02302768
    Up to 6 mo20.83660.80880.86430.00000.00020.0142292
    ANOVA Q test random effects with separate estimates of T 2 Sig <0.0001Total patient samples16,987

    • ANOVA, analysis of variance; Sig, significance level of 95% CI; VAS, visual analog scale.

  • Table 6

    Analysis of effect size, heterogeneity, and ANOVA testing of difference by surgery type.

    Type of SurgeryNumber of Studies Included in This AnalysisEffect SizeLower LimitUpper LimitHiggins I 2 Statistic of HeterogeneityVarianceStandard ErrorNumber of Patients
    Oswestry Disability IndexEndoscopic-assisted MIS fusion40.94960.90870.99050.00000.00040.0209166
    Open laminectomy50.92940.87930.97950.00000.00070.02551188
    Endoscopy810.91780.90130.93430.00000.00010.008412,710
    Tubular microdiscectomy160.89680.85430.93940.00000.00050.02172895
    Standalone endo fusion10.83370.73360.89840.00000.00170.041036
    ANOVA Q test random effects with separate estimates of T 2 Sig = 0.049Total patient samples16,995
    VAS backEndoscopic-assisted MIS fusion20.93250.80871.05630.00000.00400.063228
    Tubular microdiscectomy110.81860.69600.94130.00000.00390.06261962
    Open laminectomy40.79180.65830.92530.00000.00460.0681726
    Endoscopy340.77320.71220.83420.00000.00100.03115028
    Standalone endo fusion10.73200.57400.83740.00000.00440.066236
    ANOVA Q test random effects with separate estimates of T 2 Sig = 0.607Total patient samples7780
    VAS LEGEndoscopic-assisted MIS fusion40.93130.89450.96820.00000.00040.0188166
    Tubular microdiscectomy150.91720.87700.95740.00000.00040.02052348
    Endoscopy800.91580.90020.93150.00000.00010.008012,631
    Open laminectomy50.89290.79100.99490.00000.00270.05201188
    Standalone endo fusion10.87960.80700.92610.00000.00090.029536
    ANOVA Q test random effects with separate estimates of T 2 Sig = 0.592Total patient samples16,369

    • ANOVA, analysis of variance; MIS, minimally invasive surgery; Sig, significance level of 95% CI; VAS, visual analog scale.

  • Table 7

    Analysis of effect size, heterogeneity, and ANOVA testing of difference by type of endoscopy.

    Type of EndoscopyNumber of Studies Included in This AnalysisEffect SizeLower LimitUpper LimitHiggins I 2 Statistic of HeterogeneityVarianceStandard ErrorNumber of Patients
     Oswestry Disability IndexCombined outside-in and Interlaminar10.98050.97490.98480.00000.00000.0025124
    Interlaminar approach200.95670.94030.97320.00000.00010.00842940
    Biportal UBE endoscopy90.92990.89540.96450.00000.00030.0176960
    Transforaminal outside-in510.90440.88030.92850.00000.00020.01238198
    Transforaminal inside-out50.89670.84680.94670.00000.00070.0255962
    ANOVA Q test random effects with separate estimates of T 2 Sig < 0.0001Total patient samples13,184
     VAS backBiportal UBE endoscopy40.89430.84700.94160.00000.00060.0241336
    Interlaminar approach100.83360.76870.89840.00000.00110.0331794
    Transforaminal outside-in220.77750.69640.85860.00000.00170.04143990
    Transforaminal inside-out10.83000.64350.92353.98830.00450.067314
    ANOVA Q test random effects with separate estimates of T 2 Sig = 0.093Total patient samples5134
     VAS legCombined outside-in and interlaminar10.96600.95620.97360.00000.00000.0044124
    Interlaminar approach200.93310.91060.95560.00000.00010.01152914
    Biportal UBE endoscopy100.92710.90080.95340.00000.00020.01341002
    Transforaminal outside-in480.91120.88800.93450.00000.00010.01197954
    Transforaminal inside-out60.89120.85440.92810.00000.00040.01881111
    ANOVA Q test random effects with separate estimates of T 2 Sig <0.00001Total patient samples13,105

    • ANOVA, analysis of variance; Sig, significance level of 95% CI; UBE, uniportal biportal endoscopy; VAS, visual analog scale.

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Differential Agnostic Effect Size Analysis of Lumbar Stenosis Surgeries
Kai-Uwe Lewandrowski, Ivo Abraham, Jorge Felipe Ramírez León, José Antonio Soriano Sánchez, Álvaro Dowling, Stefan Hellinger, Max Rogério Freitas Ramos, Paulo Sérgio Teixeira De Carvalho, Christopher Yeung, Nima Salari, Anthony Yeung
International Journal of Spine Surgery Apr 2022, 16 (2) 318-342; DOI: 10.14444/8222
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