Abstract
Purpose
We conducted a systematic review and meta-analysis to compare the clinical outcomes of percutaneous endoscopic lumbar discectomy (PELD) and microendoscopic discectomy (MED) for the treatment of lumbar disc herniation (LDH), and to clarify whether PELD is more superior to MED.
Methods
We performed a comprehensive search in the databases of MEDLINE, EMBASE, PubMed, Web of Science, Cochrane database, CNKI, and Wanfang Data to acquire all relevant studies up to July 2018. The searched literatures were then screened according to the strict inclusion and exclusion criteria. The critical data were extracted and analyzed utilizing Review Manager software. The pooled effects were calculated by mean difference (MD) or odds ratio (OR) with 95% confidence intervals (CI) on the basis of data attributes.
Results
A total of 18 studies (2161 patients, 1093 in the PELD group and 1068 in the MED group) were included in this systematic review and meta-analysis. At last follow-up, the results revealed that no significant difference was found between PELD group and MED group with respect to ODI (MD − 0.30; 95% CI − 1.02 to 0.42; P = 0.41), VAS-leg pain (MD − 0.18; 95% CI − 0.45 to 0.09; P = 0.19), VAS-unspecified (MD − 0.00; 95% CI − 0.05 to 0.04; P = 0.94), excellent & good rate (OR, 1.04; 95% CI 0.68 to 1.59; P = 0.86), total complication rate (OR, 0.96; 95% CI 0.65 to 1.43; P = 0.85), dural tear rate (OR, 0.39; 95% CI 0.10 to 1.55; P = 0.18), and residue or recurrence rate (OR, 2.22; 95% CI 1.02 to 4.83; P = 0.05). When compared to MED group, the PELD group showed significantly better results with regard to shorter length of incision (MD − 1.18; 95% CI − 1.39 to − 0.97; P < 0.00001), less blood loss (MD − 45.17; 95% CI − 64.74 to − 25.60; P < 0.00001), shorter post-operative in-bed time (MD − 59.11; 95% CI − 71.19 to − 47.04; P < 0.00001), shorter post-operative hospital stay (MD − 3.07; 95% CI − 4.81 to − 1.33; P < 0.00001), shorter total hospital stay (MD − 2.29; 95% CI − 3.03 to − 1.55; P < 0.00001), and lower VAS-back pain at last follow-up (MD − 0.77; 95% CI − 1.31 to − 0.24; P = 0.005), but with significantly worse results such as more fluoroscopy (MD 7.63; 95% CI 5.25 to 10.01; P < 0.00001) and higher re-operation rate (OR, 2.67; 95% CI 1.07 to 6.67; P = 0.04). Although no significant difference was found between the two groups in terms of duration of operation (MD 6.27; 95% CI − 2.44 to 14.98; P = 0.16) and total hospital cost (MD − 0.69; 95% CI − 12.60 to 11.23; P = 0.91), further subgroup analysis revealed that the duration of operation was significantly longer in the PELD group compared with the MED group in “Years before 2016” (MD 24.97; 95% CI 7.07 to 42.87; P = 0.006) and “Year 2016 to 2017” (MD 6.57; 95% CI 0.58 to 12.55; P = 0.03) subgroups but not in the subgroup “Year 2018” (MD − 5.66; 95% CI − 18.84 to 7.53; P = 0.40), and that the total hospital cost was significantly more in the PELD group compared with the MED group in the subgroup “Southeast of China” (MD 6.67; 95% CI 3.23 to 10.28; P = 0.0002) but not in the subgroup “Midwest of China” (MD − 8.09; 95% CI − 17.99 to 1.80; P = 0.11).
Conclusions
For the treatment of LDH, both of PELD and MED can reach excellent results and no superiority was found between the two minimally invasive procedures with regard to duration of operation, ODI, VAS-leg pain, VAS-unspecified, excellent & good rate, total complication rate, dural tear rate, and residue or recurrence rate. While PELD can achieve better outcomes with respect to the length of incision, blood loss, post-operative in-bed time, post-operative hospital stay, total hospital stay, and VAS-back pain at last follow-up, however, MED showed certain advantages of less fluoroscopic times and lower re-operation rate. More practice and development are needed to make up for the deficiencies of PELD. Besides, the economic factor should also be considered according to different regions before making the treatment strategies. Well-defined randomized controlled trials with large samples are needed to further confirm these results.
Similar content being viewed by others
References
Luo X, Pietrobon R, Sun SX, Liu GG, Hey L (2004) Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine (Phila Pa 1976) 29(1):79–86. https://doi.org/10.1097/01.BRS.0000105527.13866.0F
Luoma K, Riihimaki H, Luukkonen R, Raininko R, Viikari-Juntura E, Lamminen A (2000) Low back pain in relation to lumbar disc degeneration. Spine (Phila Pa 1976) 25(4):487–492
Maroon JC (2002) Current concepts in minimally invasive discectomy. Neurosurgery 51(5):S2–137–S132–145
Smith MM, Foley KT (1997) Microendoscopic discectomy: surgical technique and initial clinical results. Clin Neurol Neurosurg 99(97):105–105(101)
Wu X, Zhuang S, Mao Z, Chen H (2006) Microendoscopic discectomy for lumbar disc herniation: surgical technique and outcome in 873 consecutive cases. Spine 31(23):2689–2694. https://doi.org/10.1097/01.brs.0000244615.43199.07
Jhala A, Mistry M (2010) Endoscopic lumbar discectomy: experience of first 100 cases. Indian J Orthop 44(2):184–190. https://doi.org/10.4103/0019-5413.62051
Smith N, Masters J, Jensen C, Khan A, Sprowson A (2013) Systematic review of microendoscopic discectomy for lumbar disc herniation. Eur Spine J 22(11):2458–2465. https://doi.org/10.1007/s00586-013-2848-8
Casal-Moro R, Castro-Menéndez M, Hernández-Blanco M, Bravo-Ricoy JA, Jorge-Barreiro FJ (2011) Long-term outcome after microendoscopic diskectomy for lumbar disk herniation: a prospective clinical study with a 5-year follow-up. Neurosurgery 68(6):1568–1575
Yeung A, Tsou P (2002) Posterolateral endoscopic excision for lumbar disc herniation: surgical technique, outcome, and complications in 307 consecutive cases. Spine 27(7):722–731
Hoogland T, Schubert M, Miklitz B, Ramirez A (2006) Transforaminal posterolateral endoscopic discectomy with or without the combination of a low-dose chymopapain: a prospective randomized study in 280 consecutive cases. Spine 31(24):E890–E897
Ruetten S, Komp M, Merk H, Godolias G (2008) Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study. Spine 33(9):931
Sinkemani A, Hong X, Gao ZX, Zhuang SY, Jiang ZL, Zhang SD, Bao JP, Zhu L, Zhang P, Xie XH, Wang F, Wu XT (2015) Outcomes of microendoscopic discectomy and percutaneous transforaminal endoscopic discectomy for the treatment of lumbar disc herniation: a comparative retrospective study. Asian Spine J 9(6):833–840. https://doi.org/10.4184/asj.2015.9.6.833
Macnab I (1971) Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients. J Bone Joint Surg Am 53(5):891–903
Oremus M, Wolfson C, Perrault A, Demers L, Momoli F, Moride Y (2001) Interrater reliability of the modified Jadad quality scale for systematic reviews of Alzheimer's disease drug trials. Dement Geriatr Cogn Disord 12(3):232–236. https://doi.org/10.1159/000051263
Higgins JPT, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21(11):1539–1558. https://doi.org/10.1002/sim.1186
Wu XC, Zhou Y, Li CQ (2009) Percutaneous transforaminal endoscopic discectomy versus microendoscopic discectomy for lumbar disc herniation: a prospective randomized controlled study. J Third Mil Med Univ 31(9):843–846. https://doi.org/10.3321/j.issn:1000-5404.2009.09.022
Yoon SM, Ahn SS, Kim KH, Kim YD, Cho JH, Kim DH (2012) 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 J Spine 9(3):215–222. https://doi.org/10.14245/kjs.2012.9.3.215
Yang L, Liao XQ, Zhao XJ, Zeng ZC, Wu RH, Guan HY, Li SY (2015) Comparison of surgical outcomes between percutaneous transforaminal endoscopic discectomy and micro-endoscopic discectomy for lumbar disc herniation. China J Endosc 21(09):962–965
Duan XF, Jin W, Chen JJ, Zheng HJ (2016) Jing pi Zhui Jian Pan Jing Xia Ji Jing Zhui Jian Kong Jing Xia sui he Zhai Chu Shu Zhi Liao Dan Chun Yao Zhui Jian Pan Tu Chu Zheng De dui Zhao guan cha (contrast observation of comparing microendoscopic discectomy with percutaneous endoscopic lumbar discectomy for the treatment of simple lumbar disc herniation). Chin J Clin (Electronic Edition) 10(1):144–147. https://doi.org/10.3877/cma.j.issn.1674-0785.2016.01.033
Zhao XW, Han K, Ji ZW, Li Z, Wang ZX, Wu P, Ding Y (2016) Comparison of efficacy between microendoscopic discectomy and percutaneous endoscopic lumbar discectomy for treatment of lumbar disc herniation. Prog Mod Biomed 16(23):4454–4457. https://doi.org/10.13241/j.cnki.pmb.2016.23.014
Ding YZ, Hu JN, Zhou Y (2017) Jing Pi Zhui Jian Kong Jing Xia Xing TESSYS Ji Shu Yu Zhui Jian Pan Jing Xia Shou Shu Zhi Liao Yao Zhui Jian Pan Tu Chu Zheng De Xiao Guo Dui Bi (study on the effect contrast between microendoscopic discectomy and percutaneous endoscopic lumbar discectomy using TESSYS technique for the treatment of lumbar disc herniation). J Cervicodynia & Lumbodynia 38(5):492–493. https://doi.org/10.3969/j.issn.1005-7234.2017.05.002
Li ZY, Guo PG, Han D, Hao JJ, Zhang GB (2017) Bu Tong Shou Shu Fang Shi Sui He Zhai Chu Shu Dui Yao Zhui Jian Pan Tu Chu Zheng Huan Zhe De Liao Xiao Ji Yu Hou Fen Xi (Analysis of curative effects and prognosis in different procedures of discectomy for patients with lumbar disc herniation). J Clin Med Pract 21(15):149–150,158. https://doi.org/10.7619/jcmp.201715048
Liu HP, Hao DJ, Wang XD, Guo H, Zhao QP, Dong XH (2017) Comparison of two surgeries in treatment of lumbar disc herniation. Chin J Pain Med 23(6):438–442. https://doi.org/10.3969/j.issn.1006-9852.2017.06.008
Luo DK, Zhou NX, Zhao HW, Chen K, Nie Y, Liu FP, Qin P (2017) Clinical effectiveness of minimally invasive treatment for lumbar disc herniation. Orthopaedics 8(6):439–444. https://doi.org/10.3969/j.issn.1674-8573.2017.06.005
Qu JX, Li QZ, Chen M (2017) PELD Yu MED Zhi Liao Dan Jie Duan Yao Zhui Jian Pan Tu Chu Zheng De Liao Xiao Bi Jiao (Comparison of the efficacies between percutaneous transforaminal endoscopic discectomy and microendoscopic discectomy for the treatment of single-segmental lumbar disc herniation). Chin J Bone Jt Inj 32(01):70–71
Song HP, Sheng HF, Xu WX (2017) A case-control study on the treatment of protrusion of lumbar intervertebral disc through PELD and MED. Exp Ther Med 14(4):3708–3712. https://doi.org/10.3892/etm.2017.4929
Chen Q, Qin L, Li MW, Chen YN, Zhou CB (2018) Comparison of the therapeutic e ect of percutaneous transforaminal endoscopic discectomy and posterior discectomy on senile single segmental lumbar disc herniation. Chin J Front Med Sci (Electronic Version) 10(02):60–64
Wu YM, Bai M, Yin HP, Li Y, Zhao J (2018) Liang Zhong Wei Chuang Shu Shi Zhi Liao Dan Chun Yao Zhui Jian Pan Tu Chu Zheng De Liao Xiao Bi Jiao (Comparison of the efficacies between two kinds of minimally invasive procedures for the treatment of simple lumbar disc herniation). J Pract Orthop 24(04):357–360
Abudurexiti T, Qi L, Muheremu A, Amudong A (2018) Micro-endoscopic discectomy versus percutaneous endoscopic surgery for lumbar disk herniation. J Int Med Res 46(9):3910–3917. https://doi.org/10.1177/0300060518781694
Chen Z, Zhang L, Dong J, Xie P, Liu B, Wang Q, Chen R, Feng F, Yang B, Shu T, Li S, Yang Y, He L, Pang M, Rong L (2018) Percutaneous transforaminal endoscopic discectomy compared with microendoscopic discectomy for lumbar disc herniation: 1-year results of an ongoing randomized controlled trial. J Neurosurg Spine 28(3):300–310. https://doi.org/10.3171/2017.7.SPINE161434
Li H, Jiang C, Mu X, Lan W, Zhou Y, Li C (2018) Comparison of MED and PELD in the treatment of adolescent lumbar disc herniation: a 5-year retrospective follow-up. World Neurosurg 112:e255–e260. https://doi.org/10.1016/j.wneu.2018.01.030
Liu X, Yuan S, Tian Y, Wang L, Gong L, Zheng Y, Li J (2018) Comparison of percutaneous endoscopic transforaminal discectomy, microendoscopic discectomy, and microdiscectomy for symptomatic lumbar disc herniation: minimum 2-year follow-up results. J Neurosurg Spine 28(3):317–325. https://doi.org/10.3171/2017.6.SPINE172
Ruan W, Feng F, Liu Z, Xie J, Cai L, Ping A (2016) Comparison of percutaneous endoscopic lumbar discectomy versus open lumbar microdiscectomy for lumbar disc herniation: a meta-analysis. Int J Surg 31:86–92. https://doi.org/10.1016/j.ijsu.2016.05.061
Kim HS, Paudel B, Jang JS, Lee K, Oh SH, Jang IT (2018) Percutaneous endoscopic lumbar discectomy for all types of lumbar disc herniations (LDH) including severely difficult and extremely difficult LDH cases. Pain Physician 21(4):E401–e408
Xiaobing Z, Xingchen L, Honggang Z, Xiaoqiang C, Qidong Y, Haijun M, Hejun Y, Bisheng W (2018) “U” route transforaminal percutaneous endoscopic thoracic discectomy as a new treatment for thoracic spinal stenosis. Int Orthop. https://doi.org/10.1007/s00264-018-4145-y
Li X, Han Y, Di Z, Cui J, Pan J, Yang M, Sun G, Tan J, Li L (2016) Percutaneous endoscopic lumbar discectomy for lumbar disc herniation. J Clin Neurosci 33:19–27. https://doi.org/10.1016/j.jocn.2016.01.043
Ding W, Yin J, Yan T, Nong L, Xu N (2018) Meta-analysis of percutaneous transforaminal endoscopic discectomy vs. fenestration discectomy in the treatment of lumbar disc herniation. Orthopade. https://doi.org/10.1007/s00132-018-3528-5
Wang K, Hong X, Zhou BY, Bao JP, Xie XH, Wang F, Wu XT (2015) Evaluation of transforaminal endoscopic lumbar discectomy in the treatment of lumbar disc herniation. Int Orthop 39(8):1599–1604. https://doi.org/10.1007/s00264-015-2747-1
Ahn S, Kim S, Kim D (2015) Learning curve of percutaneous endoscopic lumbar discectomy based on the period (early vs. late) and technique (in-and-out vs. in-and-out-and-in): a retrospective comparative study. J Korean Neurosurg Soc 58(6):539–546
Parker S, Mendenhall S, Godil S, Sivasubramanian P, Cahill K, Ziewacz J, McGirt M (2015) Incidence of low back pain after lumbar discectomy for herniated disc and its effect on patient-reported outcomes. Clin Orthop Relat Res 473(6):1988–1999. https://doi.org/10.1007/s11999-015-4193-1
Carragee E, Spinnickie A, Alamin T, Paragioudakis S (2006) A prospective controlled study of limited versus subtotal posterior discectomy: short-term outcomes in patients with herniated lumbar intervertebral discs and large posterior anular defect. Spine 31(6):653–657
Hong X, Shi R, Wang YT, Liu L, Bao JP, Wu XT (2018) Lumbar disc herniation treated by microendoscopic discectomy: prognostic predictors of long-term postoperative outcome. Orthopade. https://doi.org/10.1007/s00132-018-3624-6
Chang X, Chen B, Li HY, Han XB, Zhou Y, Li CQ (2014) The safety and efficacy of minimally invasive discectomy: a meta-analysis of prospective randomised controlled trials. Int Orthop 38(6):1225–1234. https://doi.org/10.1007/s00264-014-2331-0
Yin S, Du H, Yang W, Duan C, Feng C, Tao H (2018) Prevalence of recurrent herniation following percutaneous endoscopic lumbar discectomy: a meta-analysis. Pain Physician 21(4):337–350
Kosztowski TA, Choi D, Fridley J, Galgano M, Gokaslan Z, Oyelese A, Telfeian AE (2018) Lumbar disc reherniation after transforaminal lumbar endoscopic discectomy. Ann Transl Med 6(6):106. https://doi.org/10.21037/atm.2018.02.26
Cheng J, Wang H, Zheng W, Li C, Wang J, Zhang Z, Huang B, Zhou Y (2013) Reoperation after lumbar disc surgery in two hundred and seven patients. Int Orthop 37(8):1511–1517. https://doi.org/10.1007/s00264-013-1925-2
Matsumoto M, Watanabe K, Hosogane N, Tsuji T, Ishii K, Nakamura M, Chiba K, Toyama Y (2013) Recurrence of lumbar disc herniation after microendoscopic discectomy. J Neurol Surg A Cent Eur Neurosurg 74(4):222–227
Acknowledgements
We would like to thank Dr. Chao Hu (The First Affiliated Hospital of Zhejiang University) and Dr. Jing-Jing Deng (Suzhou Center for Disease Control and Prevention) for their great help on the methodology. We also thank Dr. Sundar Karki (Medical School, Southeast University) for his great contribution on the language checking in this document.
Funding
This work was supported by grants from the National Natural Science Foundation of China (Grant Nos. 81702201, 81702203, 81572190, and 81572170) and the Natural Science Foundation of Jiangsu Province (CN): Grant No. BK20170701.
Author information
Authors and Affiliations
Corresponding authors
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Electronic supplementary material
ESM 1
(DOCX 189 kb)
Rights and permissions
About this article
Cite this article
Shi, R., Wang, F., Hong, X. et al. Comparison of percutaneous endoscopic lumbar discectomy versus microendoscopic discectomy for the treatment of lumbar disc herniation: a meta-analysis. International Orthopaedics (SICOT) 43, 923–937 (2019). https://doi.org/10.1007/s00264-018-4253-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00264-018-4253-8