Minimally invasive surgery for lumbar disc herniation: a systematic review and meta-analysis

Purpose

Assessing the benefits of surgical treatments for sciatica is critical for clinical and policy decision-making. To compare minimally invasive (MI) and conventional microdiscectomy (MD) for patients with sciatica due to lumbar disc herniation.

Methods

A systematic review and meta-analysis of controlled clinical trials including patients with sciatica due to lumbar disc herniation. Conventional microdiscectomy was compared separately with: (1) Interlaminar MI discectomy (ILMI vs. MD); (2) Transforaminal MI discectomy (TFMI vs. MD). Outcomes: Back pain, leg pain, function, improvement, work status, operative time, blood loss, length of hospital stay, complications, reoperations, analgesics and cost outcomes were extracted and risk of bias assessed. Pooled effect estimates were calculated using random effect meta-analysis.

Results

Twenty-nine studies, 16 RCTs and 13 non-randomised studies (n = 4,472), were included. Clinical outcomes were not different between the surgery types. There is low quality evidence that ILMI takes 11 min longer, results in 52 ml less blood loss and reduces mean length of hospital stay by 1.5 days. There were no differences in complications or reoperations. The main limitations were high risk of bias, low number of studies and small sample sizes comparing TF with MD.

Conclusions

There is moderate to low quality evidence of no differences in clinical outcomes between MI surgery and conventional microdiscectomy for patients with sciatica due to lumbar disc herniation. Studies comparing transforaminal MI with conventional surgery with sufficient sample size and methodological robustness are lacking.     

Neurological examination of the peripheral nervous system to diagnose lumbar spinal disc herniation with suspected radiculopathy: a systematic review and meta-analysis

Background contextDisc herniation is a common low back pain (LBP) disorder, and several clinical test procedures are routinely employed in its diagnosis. The neurological examination that assesses sensory neuron and motor responses has historically played a role in the differential diagnosis of disc herniation, particularly when radiculopathy is suspected; however, the diagnostic ability of this examination has not been explicitly investigated.PurposeTo review the scientific literature to evaluate the diagnostic accuracy of the neurological examination to detect lumbar disc herniation with suspected radiculopathy.Study designA systematic review and meta-analysis of the literature.MethodsSix major electronic databases were searched with no date or language restrictions for relevant articles up until March 2011. All diagnostic studies investigating neurological impairments in LBP patients because of lumbar disc herniation were assessed for possible inclusion. Retrieved studies were individually evaluated and assessed for quality using the Quality Assessment of Diagnostic Accuracy Studies tool, and where appropriate, a meta-analysis was performed.ResultsA total of 14 studies that investigated three standard neurological examination components, sensory, motor, and reflexes, met the study criteria and were included. Eight distinct meta-analyses were performed that compared the findings of the neurological examination with the reference standard results from surgery, radiology (magnetic resonance imaging, computed tomography, and myelography), and radiological findings at specific lumbar levels of disc herniation. Pooled data for sensory testing demonstrated low diagnostic sensitivity for surgically (0.40) and radiologically (0.32) confirmed disc herniation, and identification of a specific level of disc herniation (0.35), with moderate specificity achieved for all the three reference standards (0.59, 0.72, and 0.64, respectively). Motor testing for paresis demonstrated similarly low pooled diagnostic sensitivities (0.22 and 0.40) and moderate specificity values (0.79 and 0.62) for surgically and radiologically determined disc herniation, whereas motor testing for muscle atrophy resulted in a pooled sensitivity of 0.31 and the specificity was 0.76 for surgically determined disc herniation. For reflex testing, the pooled sensitivities for surgically and radiologically confirmed levels of disc herniation were 0.29 and 0.25, whereas the specificity values were 0.78 and 0.75, respectively. The pooled positive likelihood ratios for all neurological examination components ranged between 1.02 and 1.26.ConclusionsThis systematic review and meta-analysis demonstrate that neurological testing procedures have limited overall diagnostic accuracy in detecting disc herniation with suspected radiculopathy. Pooled diagnostic accuracy values of the tests were poor, whereby all tests demonstrated low sensitivity, moderate specificity, and limited diagnostic accuracy independent of the disc herniation reference standard or the specific level of herniation. The lack of a standardized classification criterion for disc herniation, the variable psychometric properties of the testing procedures, and the complex pathoetiology of lumbar disc herniation with radiculopathy are suggested as possible reasons for these findings.     

Microendoscopic discectomy versus open discectomy for lumbar disc herniation: a meta-analysis

Purpose

To compare the outcomes of microendoscopic discectomy and open discectomy for patients with lumbar disc herniation.

Methods

An extensive search of studies was performed in PubMed, Medline, Embase, Cochrane library and Google Scholar. The following outcome measures were extracted: visual analogue scale (VAS), Oswestry disability index (ODI), complication, operation time, blood loss and length of hospital stay. Data analysis was conducted with RevMan 5.0.

Results

Five randomized controlled trials involving 501 patients were included in this meta-analysis. The pooled analysis showed that there was no significant difference in the VAS, ODI or complication between the two groups. However, compared with the open discectomy, the microendoscopic discectomy was associated with less blood loss [WMD = ?151.01 (?288.22, ?13.80), P = 0.03], shorter length of hospital stay [WMD = ?69.33 (?110.39, ?28.28), P = 0.0009], and longer operation time [WMD = 18.80 (7.83, 29.76), P = 0.0008].

Conclusions

Microendoscopic discectomy, which requires a demanding learning curve, may be a safe and effective alternative to conventional open discectomy for patients with lumbar disc herniation.

     

Comparison of clinical efficacy of transforaminal and caudal epidural steroid injection in lumbar and lumbosacral disc herniation: A systematic review and meta-analysis

BACKGROUND CONTEXT

Epidural steroid injection has been used to treat back or radicular pain from lumbar and lumbosacral disc herniation (LDH). However, the superiority of transforaminal injection (TFESI) to caudal injection (CESI) remains controversial.

Comparative outcomes of epidural steroids versus placebo after lumbar discectomy in lumbar disc herniation: a systematic review and meta-analysis of randomized controlled trials

European Journal of Orthopaedic Surgery & Traumatology - Treatment for lumbar disc herniation after failed conservative treatment is discectomy. Discectomy can significantly relieve back pain...     

经皮内窥镜下腰椎椎间盘切除术与显微内窥镜下椎间盘切除术治疗腰椎椎间盘突出症的荟萃分析

目的 系统分析并比较经皮内窥镜下腰椎椎间盘切除术(PELD)与显微内窥镜下椎间盘切除术(MED)治疗腰椎椎间盘突出症(LDH)的疗效.方法 利用中国知网、万方数据、维普网、中国生物医学数据库、PubMed、Embase、Cochrane Library、Ovid等数据库,检索国内外公开发表的治疗单节段LDH的中英文文献...     

Systematic review of microendoscopic discectomy for lumbar disc herniation

Study design

Systematic review.

Objective

To search and analyse randomised controlled trials (RCTs) published since the Cochrane review by Gibson and Waddell (2007) comparing microendoscopic discectomy (MED) with open discectomy (OD) or microdiscectomy (MD) and to assess whether MED improves patient-reported outcomes.

Summary of background

Discectomy for symptomatic herniated lumbar discs is an effective operative treatment. A number of operative techniques exist including OD, MD, and MED. A 2007 Cochrane review identified OD as an effective treatment for symptom improvement, and found sufficient evidence for MD. However, evidence for MED was lacking.

Methods

A systematic review of Medline and Embase was carried out. Aiming to identify RCTs carried out after 2007, which compared OD with MD and MED which reported the Oswestry disability index (ODI) as an outcome.

Results

Four RCTs were identified. None of the studies found a significant difference in the ODI scores between study groups at any time point. Three studies compared MED to OD and one compared OD, MD, and MED. The largest study reported an increased number of severe complications in the MED group.

Conclusions

There is some evidence to suggest that MED performed by surgeons skilled in the technique in tertiary referral centres is as effective as OD.     

经皮激光椎间盘气化减压术与髓核摘除术治疗腰椎间盘突出症的临床对比研究

经皮激光椎间盘气化减压术(PLDD)是Choy于1986年率先使用的一种椎间盘突出症微创治疗方法,在我国目前已有多家医院开展了这项技术。髓核摘除术是目前临床上仍普遍应用于治疗单纯腰椎椎间盘突出症的有效方法,已有较多文献报道了他们的禁忌证、适应证及其疗效。我院自2001年5月来     

MED椎间盘镜与开放手术治疗腰椎间盘突出症的比较

2001年5月～2003年5月,我科收治120例单间隙腰椎间盘突出症患者,分别采用MED和开放手术,笔者对疗效进行回顾性分析,比较两种治疗方法的优缺点,评价MED的临床价值。     

硬膜内椎间盘突出症2例报告与文献综述

硬膜内型腰椎间盘突出(intradural lumbar disc herniation, ILDH)是一种少见的腰椎间盘突出类型,占全部椎间盘突出的0.26%～0.3%,常有神经根性症状和马尾综合征。本文报道2例术前怀疑IDDH,病理检查证实为IDDH的患者,对国内外文献进行复习,对其病史、症状、临床表现、影像学特点、手术方式、预后进行总结,为该病的诊疗提出建议。     

基于社会网络分析的中医药治疗腰椎间盘突出症学术现状

[目的]应用社会网络分析和文献计量学方法,挖掘中医药治疗腰椎间盘突出症的核心作者和学术团队,并对其学术思想、研究现状及发现趋势进行分析。[方法]全面检索中医药治疗腰椎间盘突出症的中文期刊文献,采用Regex Buddy软件对作者、单位等信息进行提取,依据普莱斯定律和综合指数筛选核心作者及学术团队,采用Netdraw软件对结果进行绘图表达,总结并分析核心学术团队的学术思想、研究现状和发展趋势。[结果]研究共纳入5 660篇中文文献,筛选出核心作者47人,挖掘核心学术团队12个,并且分析了作者单位、出版年度、核心团队的学术思想及行业现状。[结论]中医药治疗腰椎间盘突出症的治疗手段丰富,其中脊柱调整手法的应用最为广泛,12支核心学术团队在该领域的研究中各自形成了独具特色的研究方向,机制研究可能是今后的发展方向。     

双侧经皮穿刺椎间盘切吸术治疗腰椎间盘突出症

自１９９６年１月到１９９７年３月,我们将１０４例腰椎间盘突出症患者随机分为单侧经皮穿刺切吸组（Ａ组）、双侧经皮穿刺切吸组（Ｂ组）。随访６～１８个月,结果显示,双侧经皮穿刺椎间盘切吸术治疗腰椎间盘突出症的疗效优于单侧穿刺切吸术。１资料与方法１１临床资...     

微创椎间盘摘除术治疗腰椎间盘突出症

腰椎间盘摘除术是脊柱外科常见手术,常用的术式有全椎板减压和半椎板减压。许多医师设计的手术器械,优化了手术技术以便提高手术疗效和减少手术死亡率。Mixter和Barr最早开始微创治疗腰椎间盘疾病。Lyman Smith经皮注射木瓜酶治疗坐骨神经痛患者,水解突出髓核组织黏蛋白。1983年Kambin和Gellmn报道了早期改良关节镜下腰椎间盘摘除术。1993年Smith等人设计了专门手术器械和内窥镜设备,在微创内窥镜下摘除突出的腰椎间盘。     

Peri-operative tobacco cessation interventions: a systematic review and meta-analysis

Tobacco smoking is associated with a substantially increased risk of postoperative complications. The peri-operative period offers a unique opportunity to support patients to stop tobacco smoking, avoid complications and improve long-term health. This systematic review provides an up-to-date summary of the evidence for tobacco cessation interventions in surgical patients. We conducted a systematic search of randomised controlled trials of tobacco cessation interventions in the peri-operative period. Quantitative synthesis of the abstinence outcomes data was by random-effects meta-analysis. The primary outcome of the meta-analysis was abstinence at the time of surgery, and the secondary outcome was abstinence at 12 months. Thirty-eight studies are included in the review (7310 randomised participants) and 26 studies are included in the meta-analysis (5969 randomised participants). Studies were pooled for subgroup analysis in two ways: by the timing of intervention delivery within the peri-operative period and by the intensity of the intervention protocol. We judged the quality of evidence as moderate, reflecting the degree of heterogeneity and the high risk of bias. Overall, peri-operative tobacco cessation interventions increased successful abstinence both at the time of surgery, risk ratio (95%CI) 1.48 (1.20–1.83), number needed to treat 7; and 12 months after surgery, risk ratio (95%CI) 1.62 (1.29–2.03), number needed to treat 9. More work is needed to inform the design and optimal delivery of interventions that are acceptable to patients and that can be incorporated into contemporary elective and urgent surgical pathways. Future trials should use standardised outcome measures.     

Cauda equina syndrome secondary to lumbar disc herniation: a meta-analysis of surgical outcomes

STUDY DESIGN: A meta-analysis of surgical outcomes of cauda equina syndrome secondary to lumbar disc herniation. OBJECTIVES: To determine the relationship between time to decompression after onset of cauda equina syndrome and clinical outcome, and to identify preoperative variables that were associated with outcomes. SUMMARY OF BACKGROUND DATA: The timing of surgical decompression for cauda equina syndrome is controversial. Although most surgeons recommend emergent decompression, results in certain studies show that delayed surgery may provide a satisfactory outcome. METHODS: A meta-analysis was performed to determine the correlation between timing of decompression and clinical outcome. One hundred four citations were reviewed, and 42 met the inclusion criteria. Preoperative and postoperative data were recorded. Length of time to surgery was broken down into five groups: less than 24 hours, 24-48 hours, 2-10 days, 11 days to 1 month, and more than 1 month. Logistic regression was used to determine the association between preoperative variables and postoperative outcomes. RESULTS: Outcomes were analyzed in 322 patients. Preoperative chronic back pain was associated with poorer outcomes in urinary and rectal function, and preoperative rectal dysfunction was associated with worsened outcome in urinary continence. In addition, increasing age was associated with poorer postoperative sexual function. No significant improvement in surgical outcome was identified with intervention less than 24 hours from the onset of cauda equina syndrome compared with patients treated within 24-48 hours. Similarly, no difference in outcome occurred in patients treated more than 48 hours after the onset of symptoms. Significant differences, however, were found in resolution of sensory and motor deficits as well as urinary and rectal function in patients treated within 48 hours compared with those treated more than 48 hours after onset of symptoms. CONCLUSIONS: There was a significant advantage to treating patients within 48 hours versus more than 48 hours after the onset of cauda equina syndrome. A significant improvement in sensory and motor deficits as well as urinary and rectal function occurred in patients who underwent decompression within 48 hours versus after 48 hours.     

Microdiscectomy for lumbar disc herniation

Surgical Principles One-level herniated or sequestrated disc material in the lumbar spinal canal is removed through a 3 cm long incision using a speculum shaped muscle retractor (speculum) and specially angulated microsurgical instruments. The surgical field is illuminated with a headlight if surgery is not performed with a microscope. Revised Version from: Operat. Orthop. Traumatol. 2 (1990), 84–92 (German Edition).     

Single position lumbar fusion: a systematic review and meta-analysis

Background ContextRecently, a single position lumbar fusion has been described in which both the anterior or lateral interbody fusion as well as posterior percutaneous pedicle screw fixation are performed in a single position.PurposeThe purpose of this study was to present and analyze the current evidence for single position lumbar fusion.Study Design/SettingThis is a systematic review and meta-analysis.Patient SampleProspective or retrospective studies published in English that assessed outcomes of single position lumbar fusion surgery for patients with lumbar degenerative disease, spondylolisthesis, or radiculopathy were included.Outcome MeasuresOutcome measures included operative time, estimated blood loss, hospital length of stay, X-Ray exposure time, and postoperative outcomes including leg numbness or pain, leg weakness, lumbar lordosis, and segmental lordosis.MethodsThis systematic review was performed in accordance with PRISMA guidelines. Two separate meta-analyses were performed. The first compared single position (SP) surgery, both lateral and prone, to dual position or flipped (F) surgery. The second meta-analysis compared lateral single position (LSP) surgery to prone single position (PSP) surgery. Variables were included if (1) they were a mean with a reported standard deviation or (2) if they were a categorical variable. For calculating standard error of the mean, we used sample size, mean, and standard deviation. A random effects model was used. The heterogeneity among studies was assessed with a significance level of <0.05.ResultsTwenty-one articles were included for analysis. Three studies were prospective nonrandomized studies, while 18 were retrospective. Seven articles studied lateral single position only, 10 articles compared lateral single position to traditional repositioning surgery, three articles studied prone single position surgery, and one article compared prone single position surgery to traditional repositioning surgery. A detailed review is provided for all 21 articles. Seventeen studies were included for meta-analysis comparing the SP versus F groups, for a total of 942 patients in the SP group and 254 in the F group. Mean operative time was significantly less for the SP group compared with the F group (SP: 127.5±7.9, F: 188.7±15.5, p<.001). Average hospital length of stay was 2.87±0.3 days in the SP group and 6.63±0.6 days in the F group (p<.001). Complication rates did not significantly differ between groups. Pedicle screws placed in the lateral position had a higher rate of complication as compared with those placed in a prone position (L: 10.2±2%, P: 1.6±1%, p=.015). Seventeen studies were included in the LSP versus PSP analysis, including 13 in the LSP group and four in the PSP group, with a total of 785 patients in the LSP group and 85 patients in the PSP group. Operative time and X-Ray exposure was significantly less in the LSP compared with the PSP group (117.1±5.5 minutes vs. 166.9±21.9 minutes, p<.001; 43.7±15.5 minutes vs. 171.0±25.8 minutes, p<.001). Postoperative segmental lordosis was greater in the prone single position group (p<.001).ConclusionsSingle position surgery decreases operative times and hospital length of stay, while maintaining similar complication rates and radiographic outcomes. PSP surgery was found to be longer in duration and have increased radiation exposure time compared with LSP, while increasing postoperative segmental lordosis.     

Comparison of early and late percutaneous endoscopic lumbar discectomy for lumbar disc herniation

Background

The optimal timing for percutaneous endoscopic lumbar discectomy (PELD) in cases of lumbar disc herniation (LDH) is debatable. This retrospective study sought to determine which category of PELD surgical intervention time resulted in greater improvement in clinical outcomes.

Methods

We retrospectively reviewed the medical records of 145 patients who underwent PELD for single-level LDH. The patients were divided into three categories according to the duration of leg pain before surgery, the early and late group being symptomatic for ≤3 months and >3 months, ≤6 months and >6 months, ≤12 months and >12 months. Surgical time, blood loss, postoperative hospital stay, hospitalization cost, rates of reoperation due to surgical failure, Macnab criteria assessment, visual analogue scale (VAS) of back pain, leg pain and numbness, Japanese orthopedic association low back pain score (JOA) before and after surgery were compared.

Results

No significant differences were found between the early and late groups according to different categories in patients’ demographics, surgical time, blood loss, preoperative and postoperative VAS (lower-back pain, leg pain and numbness) scores, JOA scores and distribution of Macnab criteria assessment. Early PELD surgical intervention did not result in greater improvement of clinical outcomes. Later surgical intervention resulted in about one-third surgical failure rates for patients being symptomatic for >6 months (≤6 months, 11/96, 11.5 %; >6 months, 2/49, 4.1 %; P?=?0.245) and >12 months (≤12 months, 12/120, 10.0 %; >12 months, 1/25, 4.0 %; P?=?0.568) of the early surgical intervention groups. Significant difference was observed between the comorbidities and non-comorbidities group in the rate of reoperation (P?=?0.040).

Conclusions

Early PELD surgical intervention did not result in greater improvement of clinical outcomes for patients with lumbar disc herniation. Later surgical intervention resulted in less failure rates for patients than the early surgical intervention groups. PELD performed when the leg pain before surgery being symptomatic for >6 months may be good for avoiding surgical failure and reducing the duration of leg pain.     

经皮内窥镜下腰椎间盘切除术治疗复发性腰椎间盘突出症并发症的Meta分析

目的 :通过Meta分析评价经皮内窥镜下椎间盘切除术(percutaneous endoscopic lumbar discectomy,PELD)治疗复发性腰椎间盘突出症(RLDH)的临床相关并发症发生率,评估手术安全性。方法 :计算机检索PubMed、EMbase、The Cochrane Library、CBM、WanFang Data和CNKI数据库,搜集有关PELD治疗RLDH相关并发症的临床研究,检索时限均为建库至2019年8月。由2名研究者独立筛选文献、提取资料并评价纳入研究的偏倚风险后,采用RevMan5.3软件进行Meta分析。结果:共纳入13个临床研究,包括1个随机对照试验和12个队列研究,共计患者1252例。Meta分析显示,PELD手术总体并发症[OR=0.46,95%CI(0.25,0.87),P=0.02]、硬脊膜撕裂发生率[OR=0.16,95%CI(0.05,0.56),P=0.004]低于椎板开窗髓核摘除术(P0.05),但与MED、MIS-TLIF相比,术后总体并发症发生率、硬脊膜撕裂、神经根损伤、髓核摘除不彻底发生率差异均无统计学意义(P0.05)。结论:PELD治疗复发性腰椎间盘突出症较椎板开窗髓核摘除术并发症发生率低,安全性较高,在排除影像学腰椎失稳的情况下,是一种较为安全有效的治疗手段。