Full-endoscopic versus micro-endoscopic and open discectomy: A systematic review and meta-analysis of outcomes and complications
Introduction
Lumbosacral radiculopathy, with an estimated lifetime prevalence of 3–5%, often leads to surgical evaluation when conservative management has failed [1], [2]. Intervertebral disc herniation is the most common cause of lumbosacral radiculopathy in the working population. Natural history suggests majority of patients will have both resolution of symptoms and radiographic regression with conservative measures, however many patients experience persistence, progressive symptoms that requires a surgical evaluation [3], [4], [5]. Severe or progressive neurological symptoms in the acute setting also merit consideration of operative intervention [6]. The surgical procedures used to treat lumbrosacral radiculopathy caused by disc herniation include open discectomy (OD) and more recently newer endoscopic techniques including microendoscopic discectomy (MED) and percutaneous full endoscopic discectomy (FED).
Open discectomy for lumbar disc herniations was first reported by 1934 for Mixer and Barr [7]. Traditional open discectomy is performed with a standard surgical incision and generally involves a laminectomy or hemilaminotomy. In order to reduce paravertebral muscle dissection and maintain posterior structural integrity, the microdiscectomy approach was introduced and involves a smaller incision with visualization through an operating microscope. Minimally invasive techniques, such as MED and FED, involve even smaller incisions with the aid of endoscopic visualization and illumination [8]. Foley and Smith reported an early experience of the MED technique in 1997, performed by a transmuscular approach using tubular retractors in combination with advanced optics of an endoscope [9], [10]. More recently, FED was introduced, which allowed a minimally invasive access to the spinal canal under continuous visualization, either via a transforaminal [11] or interlaminar corridor [12], [13]. Proponents of the minimally invasive approach using endoscopy have claimed potential benefits of faster recovery, reduced complication rates and improved visualization of the anatomy when compared to an open approach.
The evidence comparing different approaches for discectomy has lacked definitive conclusions, with conflicting results regarding the benefit of minimally invasive versus open techniques for discectomy [14], [15], [16], [17], [18], [19]. Furthermore, the relative benefits and risks of specifically full-endoscopic versus microendoscopic techniques have not been well established. The current systematic review and meta-analysis aims to compare the clinical outcomes and complications associated with FED, MED and OD approaches for lumbar discectomy.
Section snippets
Literature search
The present review was conducted according to PRISMA guidelines and recommendations [20], [21], [22]. Electronic searches were conducted using Ovid Medline, PubMed, Cochrane Central Register of Controlled Trials (CCTR), Cochrane Database of Systematic Reviews (CDSR), American College of Physicians (ACP) Journal Club and Database of Abstracts of Review of Effectiveness (DARE) from their dates of inception to February 2016. The identification of applicable studies was maximized by combining the
Literature search
A total of 680 references were identified via electronic database searches. After exclusion of duplicate or irrelevant references, 664 potentially relevant articles were retrieved. After detailed evaluation of these articles, 81 studies remained for assessment. After applying the selection criteria [23], studies [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47] were selected for analysis (Fig. 1), including
Discussion
The present systematic review and meta-analysis pooled available evidence comparing either FED or MED outcomes to those of OD and demonstrated: (1) no significant differences between any of the discectomy procedures with regards to postoperative VAS leg and ODI scores, (2) shorter hospital stays in FED, MED, and endoscopic surgery overall in comparison to OD, (3) reduced blood loss with the endoscopic approach compared to open surgery, and (4) similar rates of complications and reoperations
Conclusions
Based on the current analysis, endoscopic approach was associated with similar postoperative VAS leg and ODI scores, but improved patient satisfaction and lower operating time, blood loss and hospital stay in comparison to open approaches. FED and MED appear to be safe and efficacious alternatives to traditional approaches, but these results require further investigation and validation by adequately powered randomized prospective studies.
Disclosures
The authors have no funding source or conflicts of interest to disclose.
Acknowledgement
None.
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