Full-endoscopic versus micro-endoscopic and open discectomy: A systematic review and meta-analysis of outcomes and complications

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Highlights

  • Minimally invasive techniques are used in a variety of spine procedures.

  • Endoscopic discectomy can be either micro-endoscopic or full-endoscopic.

  • No difference was found in complications between endoscopic and open approaches.

  • Endoscopic approaches are safe and efficacious alternatives to traditional approaches.

Abstract

Objectives

The purpose of this study was to systematically compare the effectiveness and safety of full-endoscopic discectomy (FED) and micro-endoscopic discectomy (MED) with open discectomy (OD) for the treatment of symptomatic lumbar disc herniation.

Methods

Electronic searches were performed using six databases from their inception to February 2016, identifying all relevant randomized controlled trials and comparative observational studies comparing either FED or MED with OD. Data were extracted and analyzed according to predefined clinical endpoints.

Results

Twenty three studies were selected for analysis, including 421 FED, 6914 MED, and 21,152 OD cases. No significant difference was found between FED and OD in regards to postoperative visual analog scale (VAS) leg pain scores (WMD 0.03, P = 0.93). Similar results were obtained for MED vs OD (WMD 0.09, P = 0.18). In terms of postoperative Oswestry disability index (ODI), both FED and MED were similar to OD (WMD −2.60, P = 0.32 and WMD −1.00, P = 0.21, respectively). FED had a significantly shorter operative duration compared to OD (54.6 vs 102.6 min, P = 0.0001). MED alone and endoscopic approaches overall (including MED and FED) demonstrated significantly lower estimated blood loss (44.3 vs 194.4 mL, P = 0.03 and 38.2 vs 203.5 mL, respectively, both p < 0.05). FED alone demonstrated a trend towards lower estimated blood loss in comparison to OD (3.3 vs 244.9 mL, P = 0.07). No difference was found in overall complications, recurrence or reoperation rates, dural tears, root injury, wound infections, and spondylodiscitis between FED vs OD, or MED vs OD.

Conclusions

Based on this meta-analysis, FED and MED appear to be safe and efficacious alternatives to traditional approaches, but these results require further investigation and validation by prospective randomized studies.

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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