Percutaneous Endoscopic Lumbar Discectomy Versus Posterior Open Lumbar Microdiscectomy for the Treatment of Symptomatic Lumbar Disc Herniation: A Systemic Review and Meta-Analysis

Highlights

• A comprehensive retrieval of related studies in four electronic databases.

• The primary outcome measurements: VAS score of sciatica; ODI; the Excellent and Good outcome rate.

• We consider that PELD is a relatively more minimally invasive technique.

Objective

The purpose of this systematic review and meta-analysis was to compare the clinical efficacy between percutaneous endoscopic lumbar discectomy (PELD) versus posterior open lumbar microdiscectomy (OLMD) for the treatment of symptomatic lumbar disc herniation.

Methods

We performed a comprehensive retrieval of related studies in 4 electronic databases (PubMed, Embase, Web of Science, and the Cochrane Library). Randomized or nonrandomized controlled trials reported from January 1990 to December 2017 that compared PELD versus OLMD for the treatment of symptomatic lumbar disc herniation were acquired. The quality of randomized controlled trials was evaluated by the criteria of the Cochrane Back Review Group, and the quality of cohort studies was assessed according to the Newcastle-Ottawa Scale. The primary outcome measurements included preoperative and postoperative visual analog scale (VAS) score of sciatica; the Oswestry Disability Index (ODI) before and after surgery; the Excellent and Good outcome rate based on Macnab criteria. The secondary outcome measurements included the incidence of complication, residual disk, recurrence, and reoperation; operation time; hospital stay; and time to return to work. Two authors independently extracted data and assessed each study for quality.

Results

Nine studies with 1585 patients were included in our meta-analysis. Two were randomized controlled trials and the remaining 7 were retrospective cohort studies. The forest plots showed that no statistically significant difference was observed between the 2 groups in terms of preoperative and postoperative VAS score of sciatica, ODI before and after surgery, the Excellent and Good outcome rate, the complication rate, and the incidence of recurrence and reoperation. However, the PELD group had a higher incidence of residual disk or incomplete decompression than did the OLMD group. In addition, no significant difference was detected in the operation time between the 2 groups, but the PELD group was associated with shorter hospital stay and time of return to work.

Conclusions

Based on the present meta-analysis, no significant difference existed in VAS and ODI scores between the 2 surgical procedures, and they were also similar in terms of operation time, complication rate, and incidence of recurrence and reoperation, but PELD showed shorter hospital stay and time of return to work. Thus, under the premise of careful manipulation and complete decompression, we consider that PELD is a relatively more minimally invasive technique, which could be an alternative to OLMD.

Introduction

Symptomatic lumbar disc herniation (LDH) is a disturbing disease which presents with the clinical symptom of low back pain and/or sciatica.¹ Conservative treatment usually achieves a satisfactory result. For those from whom a period of conservative treatment failed, surgery seems inevitable.² Mixter and Barr first attempted posterior partial laminectomy to resect herniated discs and decompress nerve roots for surgical treatment of LDH in 1934.³ In the late 1970s, on the basis of posterior laminectomy, Caspar and Yasargil introduced microscope discectomy for treating LDH, which was more minimally invasive.⁴ Since then, open lumbar microdiscectomy (OLMD) has been considered as a gold standard surgical treatment for symptomatic LDH.5, 6 In the late 1980s and early 1900s, Kambin et al.⁷ used an endoscopic or arthroscopic approach for lumbar decompressive surgery through a transforaminal approach. The endoscope interlaminar approach was reported in the late 1990s.8, 9 Then, with the improvement of endoscopic instruments and operative technique, the practical method called percutaneous endoscopic lumbar discectomy (PELD) is widely used for symptomatic LDH and other spinal surgery and seems to incur less soft tissue trauma, more preservation of bone, and faster recovery.10, 11, 12 Simultaneously, complications of OLMD such as postoperative spinal instability and epidural scar rarely occur in PELD.

However, because the 2 minimally invasive procedures both achieve satisfactory treatment results,13, 14 it remains controversial whether PELD could challenge OLMD for supremacy as the gold standard treatment. Thus, we performed a systematic review and meta-analysis to evaluate the clinical outcomes of PELD compared with OLMD for the treatment of symptomatic LDH.