Abstract
OBJECTIVES:
To explore the microendoscopic discectomy technique and inclusion criteria for the treatment of recurrent lumbar disc herniation and to supply feasible criteria and technical notes to avoid complications and to increase the therapeutic effect.
METHODS:
A consecutive series of 25 patients who underwent posterior microendoscopic discectomy for recurrent lumbar disc herniation were included. The inclusion criteria were as follows: no severe pain in the lumbar region, no lumbar instability observed by flexion-extension radiography and no intervertebral discitis or endplate damage observed by magnetic resonance imaging. All patients were diagnosed by clinical manifestations and imaging examinations.
RESULTS:
Follow-up visits were carried out in all cases. Complications, such as nerve injuries, were not observed. The follow-up outcomes were graded using the MacNab criteria. A grade of excellent was given to 12 patients, good to 12 patients and fair to 1 patient. A grade of excellent or good occurred in 96% of cases. One patient relapsed 3 months after surgery and then underwent lumbar interbody fusion and inner fixation. The numerical rating scale of preoperative leg pain was 7.4± 1.5, whereas it decreased to 2.1±0.8 at 7 days after surgery. The preoperative Oswestry disability index of lumbar function was 57.5±10.0, whereas it was 26.0±8.5 at 7 days after surgery.
CONCLUSION:
In these cases, microendoscopic discectomy was able to achieve satisfactory clinical results. Furthermore, it has advantages over other methods because of its smaller incision, reduced bleeding and more efficient recovery.
Microendoscopic Discectomy; Lumbar Intervertebral Disc Herniation; Recurrence in situ; Inclusion Criteria
INTRODUCTION
In recent years, microendoscopic discectomy (MED) for lumbar disc herniation has been
widely applied in clinical practice due to its minimal exposure and certain efficacy
(11 Boult M, Fraser RD, Jones N, Osti O, Dohrmann P, Donnelly P, et
al. Percutaneous endoscopic laser discectomy.
Aust N Z J Surg. 2000; 70(7):475-9.
2 Choy DS. Percutaneous laser disc decompression (PLDD): Twelve
years' experience with 752 procedures in 518 patients. J Clin Laser
Med Surg. 1998;16(6):325-31.
3 Gangi A, Dietemann JL, Ide C, Brunner P, Klinkert A, Warter JM.
Percutaneous laser disk decompression under CT and fluoroscopic guidance:
Indications, techniques, and clinical experience. Radiographics.
1996;16(1):89-96,
http://dx.doi.org/10.1148/radiographics.16.1.89.
http://dx.doi.org/10.1148/radiographics....
4 Marks RA. Transcutaneous lumbar diskectomy for internal disk
derangement: A new indication. South Med J.
2000;93(9):885-90.-55 Maroon JC, Onik G, Vidovich DV. Percutaneous discectomy for
lumbar disc herniation. Neurosurg Clin N Am.
1993;4(1):125-34.). The recurrence rate of MED is between 3.5% and 10.8% (66 Wang M, Zhou Y, Wang J, Zhang Z, Li C. A 10-year follow-up study
on long-term clinical outcomes of lumbar microendoscopic discectomy.
J Neurol Surg A Cent Eur Neurosurg.
2012;73(4):195-8.
7 Matsumoto M, Watanabe K, Hosogane N, Tsuji T, Ishii K, Nakamura
M, et al. Recurrence of lumbar disc herniation after microendoscopic discectomy.
J Neurol Surg A Cent Eur Neurosurg.
2013;74(4):222-7.-88 Moliterno JA, Knopman J, Parikh K, Cohan JN, Huang QD, Aaker GD,
et al. Results and risk factors for recurrence following single-level tubular
lumbar microdiscectomy. J Neurosurg Spine. 2010;12(6):680-6,
http://dx.doi.org/10.3171/2009.12.SPINE08843.
http://dx.doi.org/10.3171/2009.12.SPINE0...
).
The treatment of recurrent disc herniation usually uses an open technique with a
wide exposure for discectomy or lumbar interbody fusion (99 Osterman H, Sund R, Seitsalo S, Keskimäki I. Risk of
multiple reoperations after lumbar discectomy: a population-based study. Spine
(Phila Pa 1976). 2003;28(6):621-7.
10 Papadopoulos EC, Girardi FP, Sandhu HS, Sama AA, Parvataneni HK,
O'Leary PF, et al. Outcome of revision discectomies following recurrent
lumbar disc herniation. Spine (Phila Pa 1976). 2006;31(13):1473-6,
http://dx.doi.org/10.1097/01.brs.0000219872.43318.7a.
http://dx.doi.org/10.1097/01.brs.0000219...
-1111 Silvers HR, Lewis PJ, Asch HL, Clabeaux DE. Lumbar diskectomy
for recurrent disk herniation. J Spinal Disor.
1994;7(5):408-19.). MED is seldom
used in clinical practice and is considered to be contraindicated for the treatment
of recurrent disc herniation due to extensive adhesion in the spinal canal,
difficult exposure and potential damage to the nerve root and dural sac (1212 Perez-Cruet MJ, Foley KT, Isaacs RE, Rice-Wyllie L, Wellington
R, Smith MM, et al. Microendoscopic lumbar discectomy: technical note.
Neurosurgery. 2002;51(5 Suppl):129-36.). Open discectomy with considerable trauma,
in essence, also involves adhesions and difficult exposure as well as the
complications of dural sac rupture and nerve injury (1111 Silvers HR, Lewis PJ, Asch HL, Clabeaux DE. Lumbar diskectomy
for recurrent disk herniation. J Spinal Disor.
1994;7(5):408-19.). Adjacent segment disease and its influence on lumbar function after
vertebrae fusion surgery are the main reasons that patients are unwilling to opt for
fusion (1313 Rahm MD, Hall BB. Adjacent-segment degeneration after lumbar
fusion with instrumentation: a retrospective study. J Spinal Disord.
1996;9(5):392-400.
14 Nagata H, Schendel MJ, Transfeldt EE, Lewis JL. The effects of
immobilization of long segments of the spine on the adjacent and distal facet
force and lumbosacral motion. Spine (Phila Pa 1976). 1993;18(16):2471-9,
http://dx.doi.org/10.1097/00007632-199312000-00017.
http://dx.doi.org/10.1097/00007632-19931...
-1515 Park P, Garton HJ, Gala VC, Hoff JT, McGillicuddy JE. Adjacent
segment disease after lumbar or lumbosacral fusion: review of the literature.
Spine (Phila Pa 1976). 2004;29(17):1938-44,
http://dx.doi.org/10.1097/01.brs.0000137069.88904.03.
http://dx.doi.org/10.1097/01.brs.0000137...
). For some patients who previously underwent MED but suffer recurrent
lumbar disc herniation in situ, MED reoperation may also be an
ideal choice because of the superior stability of the lumbar vertebrae and the
absence of significant facet joint degeneration. This study focuses on the choice of
cases and the suggested selection criteria and the corresponding technical notes.
Through long-term follow-up and subsequent evaluations, the outcomes of this study
were used to analyze the availability of selection criteria and the corresponding
technical notes.
PATIENTS AND METHODS
Clinical data
This is a prospective study. A consecutive series of 25 patients (12 males and 13 females) who underwent posterior MED for recurrent lumbar disc herniation between September 2004 and June 2007 were included (Table 1). The ages of the patients ranged from 27 to 62 years old (mean, 50 years old). All segments were at either L4-5 (13 cases) or L5-S1 (12 cases). Before surgery for recurrent herniation, all patients underwent preoperative X-ray imaging, computed tomography and magnetic resonance imaging (MRI) examinations. For those patients without an obvious location sign, electromyography was also performed. All cases were clearly diagnosed based on their clinical manifestations (Figure 1).
Summary of the surgical parameters for 25 patients undergoing microendoscopic discectomy for recurrent herniation.
Typical case: Female, 27 years old, relapsed one year after microendoscopic discectomy for L5S1 disc herniation. The lumbar disc herniated, along with repeated annulus fibrosus rupture in situ (see arrows). The X-ray showed fair stability of the lumbar spine, no significant decrease in the intervertebral space, and unobvious facet joint degeneration. Microendoscopic discectomy was applied along the original surgical approach (line shown), and the exposed herniated disc was removed from the interior facet joint.
Inclusion criteria
All patients underwent conservative treatment for 1-6 months. Treatment measures included position restriction, nonsteroidal anti-inflammatory drug administration and physical therapy. Surgery was performed when the treatment efficacy was not obvious or the symptoms suddenly worsened. For example, leg pain limits normal activities; there is weakness and numbness in leg; it is difficult to walk and stand; medication and physical therapy are ineffective; the surgery is recommended. Inclusion criteria for this study were as follows: the relatively intact facet of joint was retained with a surgical excision no more than a half and no serious back pain, lumbar spine instability, lumbar disc endplate inflammation, or lumbar disc endplate damage were present.
Surgical technique
The surgical technique used was the same as the standard MED treatment for primary lumbar disc herniation but included scar dissection.
Surgical instrument
A microendoscopic discectomy type II (Sofamor Danek, USA) instrument, a matched image pick-up system, bayonetted forceps, nucleus pulposus forceps, and a curved curette were used for the procedure.
Surgical procedure
The surgery was performed under epidural anesthesia or general anesthesia with
the patient in the prone position, with flexed hips and knees and the
patient's abdomen in the suspended position to reduce nerve root tension
and prevent bleeding caused by spinal venous plexus expansion (Figure 2) (11 Boult M, Fraser RD, Jones N, Osti O, Dohrmann P, Donnelly P, et
al. Percutaneous endoscopic laser discectomy.
Aust N Z J Surg. 2000; 70(7):475-9.). For the incision, the body surface corresponding to the
diseased disc coronal axis was located using an anteroposterior X-ray and the
surface position line was taken as the center. A 1.5-cm longitudinal incision
was then laterally opened 0.5 cm from the spinal midline (22 Choy DS. Percutaneous laser disc decompression (PLDD): Twelve
years' experience with 752 procedures in 518 patients. J Clin Laser
Med Surg. 1998;16(6):325-31.). To reveal the laminar space, the lumbodorsal fascia was
incised 1-1.5 cm along the edge of the spinous process, the paraspinal muscles
were moved with a 1-cm wide periosteal dissector and the secondary expansion
tube was inserted and propped against the vertebral plate. This opening was
progressively expanded and the operating channel was then installed; the scar
tissue and residual muscle tissue between the vertebral plates were cleaned and
the bone border of the last fenestration operation was revealed (Figure 2A) (33 Gangi A, Dietemann JL, Ide C, Brunner P, Klinkert A, Warter JM.
Percutaneous laser disk decompression under CT and fluoroscopic guidance:
Indications, techniques, and clinical experience. Radiographics.
1996;16(1):89-96,
http://dx.doi.org/10.1148/radiographics.16.1.89.
http://dx.doi.org/10.1148/radiographics....
). To enter into the spinal canal and incise, the adhesion
between the bone border and scar tissue was dissected with a nerve dissector or
Kerrison based on the anatomical and imaging features. This procedure was
repeated against the spinal canal bone surface with a 90-degree short spherical
probe or dissector and then the adhesion was rotated, probed and dissected.
Next, the scar tissue was carefully removed or resected and the window was
expanded to the desired range with a Kerrison (Figure 2B) (44 Marks RA. Transcutaneous lumbar diskectomy for internal disk
derangement: A new indication. South Med J.
2000;93(9):885-90.). To
reveal the disc herniation, the anatomical relationship between the dural sac
and the nerve root was carefully identified and then the adhesion, the inward
retracting nerve root and the dural sac on the surface of the disc herniation
were dissected with a 90-degree short spherical probe or dissector. The nerve
root and dural sac were then fixed and protected with a nerve retractor and wire
retractor with a suction tube to clearly expose the herniation (Figure 2C) (55 Maroon JC, Onik G, Vidovich DV. Percutaneous discectomy for
lumbar disc herniation. Neurosurg Clin N Am.
1993;4(1):125-34.). The intervertebral disc herniation was then incised and
the broken disc tissue was removed; to avoid harming the nerve roots, the
availability of the corresponding segmental nerve root and the anatomical
variations of the corresponding segments of the nerve roots and upper nerve root
were identified (Figure 2D) (66 Wang M, Zhou Y, Wang J, Zhang Z, Li C. A 10-year follow-up study
on long-term clinical outcomes of lumbar microendoscopic discectomy.
J Neurol Surg A Cent Eur Neurosurg.
2012;73(4):195-8.). The corresponding segmental nerve root
lateral recess and the upper nerve root canal were then explored and
decompressed by ensuring that a 90-degree, long spherical probe or dissector
could be placed inside and easily moved up and down without any blockage.
Special attention was paid as excessive manipulation may cause serious damage to
the intervertebral joint, thereby affecting the postoperative inter-vertebral
stability (77 Matsumoto M, Watanabe K, Hosogane N, Tsuji T, Ishii K, Nakamura
M, et al. Recurrence of lumbar disc herniation after microendoscopic discectomy.
J Neurol Surg A Cent Eur Neurosurg.
2013;74(4):222-7.). Then, the spinal canal was
explored and cleaned. Whether the disc herniation was a free or prolapse type
and whether free nucleus pulposus tissue residue was present in the periphery of
the dural sac, nerve front, lateral recess and nerve root canal was determined
using a 90-degree, long spherical probe or dissector. The ossification growths
on the posterior lumbar edge and the protruded annulus fibrosus attachment,
which cause compression of the nerve roots, were then removed. This step often
caused bleeding. The spinal canal and intervertebral space were then washed with
300-500 ml of ice-cold normal saline; if there were slight ruptures in the dural
sac and nerve root sleeve portion, a cotton sheet was placed over them during
the operation. After detecting and cleaning the spinal canal, a gelatin sponge
was placed over it. If there was considerable damage to the dural sac and nerve
root sleeve portion, MED was changed to open surgery to repair the damage.
The technical note for repeated microendoscopic discectomy for recurrent lumbar disc herniation is displayed using a schematic diagram. A: The paraspinal muscles are first moved in the original incision and the secondary expansion tube is inserted and propped against the vertebral plate. Then, the operating channel is progressively expanded and installed, the scar tissue and residual muscle tissue between the vertebral plates are cleaned and the bone border of the last fenestration operation is revealed. B: The adhesion between the bone border and scar tissue is dissected (see arrows) with a nerve dissector or Kerrison based on anatomy and imaging features and the scar tissue is further carefully removed or resected. The window is then expanded to the desired range with a Kerrison. C: The anatomical relationship between the dural sac and nerve root is then carefully identified, the adhesion is then dissected and the nerve root and dural sac are inwardly retracted on the surface of the disc herniation with a 90-degree short spherical probe or dissector. Then, the herniation can be clearly exposed. D: The intervertebral disc herniation is incised and the broken disc tissue is removed.
Postoperative treatment and follow-up visits
The routine postoperative anti-inflammatory treatment with a glucocorticoid and dehydration treatment with mannitol was followed for 5-7 days. The patients were provided back muscle training after 3-5 days and ambulation with a leather waist girdle after 5-7 days. The patients resumed their daily activities without a waist girdle 3 weeks later. Outpatient follow-up visits were conducted in the 1st, 3rd, 6th, 9th and 12th months after surgery and every 6 months thereafter. The primary outcomes included a numerical rating scale (0-10) and lumbar function Oswestry disability index (ODI) scoring (0% represents no pain and no disability and 100% represents the worst possible pain and disability). The secondary outcomes included the operative time, blood loss, postoperative analgesics, reoperation and complication rates, and MacNab criteria (1616 MacNab I Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients. J Bone Jt Surg Am. 1971;53(5):891-903.). X-ray examinations in the L-spine anteroposterior position, L-spine lateral position and L-spine lordotic kyphotic position were routinely taken and an MRI was performed annually or when nerve symptoms occurred. Nonsteroidal anti-inflammatory medication was administered if necessary.
All data are presented as the mean ± STD and subjected to a paired Student's t test (numerical rating scale) and one-way ANOVA (ODI scores) with the SPSS version 11.0 software package. Differences were considered significant if p<0.05.
RESULTS
The operation time ranged from 60 to 100 min (mean, 85 min). The average blood loss was 68 ml (range: 20 to 100 ml). No nerve root or cauda equina injury was observed. A small dural tear, observed in three patients, was covered with a gelatin sponge without any repair. No postoperative cerebrospinal fluid leakage occurred. All incisions healed by first intention.
Follow-up visits took place over a 1-6-year period (mean, 3 years) and were undertaken in all cases. The clinical outcomes were graded using the MacNab criteria. A grade of excellent was given to 12 patients based on the resolution of preoperative symptoms, normal results in the straight leg raising test, good lumbar segment motion and partial nerve function recovery. These patients were able to return to normal work. A grade of good was given to 12 patients who displayed relief of their preoperative symptoms, occasional pain and somewhat improved functional capacity. These patients were able to return to modified work. A grade of fair was given to one patient who displayed an improvement of symptoms but still experienced pain and was unable to work. A grade of excellent or good occurred in 96% of cases. One case was not included in the follow-up data because the patient relapsed 3 months after surgery and then underwent lumbar fusion. X-rays showed fusion in the operated segment at 3 months after the operation.
The numerical rating scale of preoperative leg pain was 7.4±1.5; this value decreased to 2.1±0.8 after surgery, giving a statistically significant difference (p<0.05). The preoperative ODI of lumbar function was 57.5±10.0, whereas it was 26.0±8.5 at 7 days after surgery. Follow-ups showed that lumbar function was significantly improved after surgery and recovered to the optimal condition 3 months after surgery, with no significant changes thereafter. There was also a statistically significant difference between the preoperative and postoperative ODI scores (p<0.05) (Figure 3).
The Oswestry disability index curve from pre-operation to six years post-operation. The number of patients is labeled on the curve.
Imaging revealed the degenerative tendency of the treated segment over time. X-ray examination showed the decreasing height of the treated intervertebral space, facet joint degeneration and lumbar instability. MRI revealed degeneration of the intervertebral discs in the treated segments as well as mild herniation.
DISCUSSION
The major problems with using posterior MED for recurrent lumbar disc herniation are
the limited surgical field, the adhesion caused by surgical scarring and
complications, such as potential dural tearing and nerve root injury (1717 Kim CH, Chung CK, Jahng TA, Yang HJ, Son YJ. Surgical outcome of
percutaneous endoscopic interlaminar lumbar diskectomy for recurrent disk
herniation after open diskectomy. J Spinal Disord Tech. 2012;25(5):
125-33.
18 Nomura K, Yoshida M, Kawai M, Okada M1, Nakao S. A novel
microendoscopically assisted approach for the treatment of recurrent lumbar disc
herniation: transosseous discectomy surgery. J Neurol Surg A Cent
Eur Neurosurg. 2014;75(3):183-8.
19 Smith JS, Ogden AT, Shafizadeh S, Fessler RG. Clinical outcomes
after microendoscopic discectomy for recurrent lumbar disc herniation.
J Spinal Disord Tech. 2010;23(1):30-4,
http://dx.doi.org/10.1097/BSD.0b013e318193c16c.
http://dx.doi.org/10.1097/BSD.0b013e3181...
20 Koga S, Sairyo K, Shibuya I, Kanamori Y, Kosugi T, Matsumoto H,
et al. Minimally invasive removal of a recurrent lumbar herniated nucleus
pulposus by the small incised microendoscopic discectomy interlaminar approach.
Asian J Endosc Surg. 2012;5(1):34-7.
21 Eloqayli H, Al-omari M. Percutaneous discectomy: minimally
invasive method for treatment of recurrent lumbar disc herniation. Clin Neurol
Neurosurg. 2012;114(7):871-5,
http://dx.doi.org/10.1016/j.clineuro.2012.01.015.
http://dx.doi.org/10.1016/j.clineuro.201...
-2222 Isaacs RE, Podichetty V, Fessler RG. Microendoscopic discectomy
for recurrent disc herniations. Neurosurg Focus.
2003;15(3):E11.).
All of the factors mentioned above might be risks of failing to relieve the symptoms
caused by recurrent lumbar disc herniation. Once the surgery fails, reoperation is
required. To reduce the complications caused by reoperation, most surgeons choose to
widely expose the recurrent herniated disc lesion and reconstruct lumbar spine
stability by fusion rather than by MED as MED is considered to be contraindicated in
the treatment of recurrent lumbar disc herniation (1212 Perez-Cruet MJ, Foley KT, Isaacs RE, Rice-Wyllie L, Wellington
R, Smith MM, et al. Microendoscopic lumbar discectomy: technical note.
Neurosurgery. 2002;51(5 Suppl):129-36.). However, the clinical observations of the patients in this study
showed that MED for recurrent lumbar disc herniation in situ still
has a good effect if appropriate patients are strictly selected.
All patients in this study were diagnosed by symptoms, signs and imaging evidence.
For patients with unobvious signs of localization, further electrophysiological
examination was conducted. For patients with recurrent lumbar disc herniation
in situ, the technical difficulty of MED for re-discectomy lies
in the dissection of scar tissue, the identification and exposure of the extraspinal
structure, the avoidance of nerve root and dural injury, and the minimization of
facet joint interior bone resection. Regarding the pathological characteristics,
most recurrent disc herniation in situ cases are of the disc
prolapse type, especially those recurrences that occur a short time after MED, most
of which are caused by omission of the free nucleus pulposus within the
intervertebral space and its repeated dislocation into the spinal canal (2323 Lee JK, Amorosa L, Cho SK, Weidenbaum M, Kim Y. Recurrent lumbar
disk herniation. J Am Acad Orthop Surg. 2010;18(6):327-37.). Prolapsed intervertebral disc tissue was
limited to annulus fibrosus rupture due to scar tissue adhesions, thus allowing
easier elimination of nerve root compression during surgery without a wide exposure.
Because the scar tissue is encountered first, reaching the herniation of the nucleus
pulposus is the key problem. In the conventional view, the scar tissue should be
completely cleared. However, clearing the scar tissue from the neural tissue easily
leads to spinal dural fracture. The incidence of spinal dural fracture during open
surgery is 8-18% (2424 Dai LY, Zhou Q, Yao WF, Shen L. Recurrent lumbar disc herniation
after discectomy: outcome of repeat discectomy. Surg Neurol. 2005;64(3):226-31,
http://dx.doi.org/10.1016/j.surneu.2004.11.003.
http://dx.doi.org/10.1016/j.surneu.2004....
), whereas that of MED is
13% (1919 Smith JS, Ogden AT, Shafizadeh S, Fessler RG. Clinical outcomes
after microendoscopic discectomy for recurrent lumbar disc herniation.
J Spinal Disord Tech. 2010;23(1):30-4,
http://dx.doi.org/10.1097/BSD.0b013e318193c16c.
http://dx.doi.org/10.1097/BSD.0b013e3181...
), indicating similar incidences.
Scarring generally does not generate nerve compression symptoms, but a small amount
of herniated nucleus pulposus tissue could cause nerve compression if the nerve
tissue adheres to the scar tissue. Even if the scar tissue has been cleared, the
nerve tissue could still be at risk for adhesion caused by repeated postoperative
scarring. Therefore, in this series of surgical operations, the dissection of the
scar tissue from the nerve was not emphasized. In contrast, scar tissue adherence to
the nerve tissue can protect the nerve tissue when the nucleus pulposus is excised
from it. All dural rupture cases in this series occurred due to the attempt to
dissect scar tissue from neural tissue (3 cases, 12% incidence), with no significant
difference compared to other studies (1919 Smith JS, Ogden AT, Shafizadeh S, Fessler RG. Clinical outcomes
after microendoscopic discectomy for recurrent lumbar disc herniation.
J Spinal Disord Tech. 2010;23(1):30-4,
http://dx.doi.org/10.1097/BSD.0b013e318193c16c.
http://dx.doi.org/10.1097/BSD.0b013e3181...
).
The surgeon discovered that the herniated nucleus pulposus mostly gathered in the
annulus fibrosus rupture (the lateral or ventral portion of the nerve roots).
Therefore, the herniated nucleus pulposus could be accessed from the medial border
of the facet joint and vertebral pedicle. It is relatively safe to dissect scar
tissue from the bone walls. Based on dissecting or cutting the scar tissue from the
bone border, the surgeon should fenestrate the bone tissue to the desired range
without damaging the dural region and nerve to explore and dissect the adhesion
tissue, reveal the dural sac and nerve root, further remove the prolapsed
intervertebral disc tissue and clean up the loose nucleus pulposus tissue within the
intervertebral space to achieve complete decompression and relapse prevention.
Cleaning up the intervertebral disc tissue within the intervertebral space is an
effective way to prevent recurrence, but excessive removal should be avoided to
prevent significantly decreasing the height of the vertebrae interval. Based on our
experience, disc tissues that can be easily removed with a nucleus pulposus clamp
must be removed, whereas a tough and tenacious nucleus pulposus cannot be forcibly
removed. For patients with recurrent disc herniation, the operation time was 85 min,
which did not significantly differ from that of open surgery (88.9 min) (2525 Suk KS, Lee HM, Moon SH, Kim NH. Recurrent lumbar disc
herniation: results of operative management. Spine (Phila Pa 1976).
2001;26(6):672-6,
http://dx.doi.org/10.1097/00007632-200103150-00024.
http://dx.doi.org/10.1097/00007632-20010...
). In this study, 12 cases had excellent
outcomes (48%), 12 cases had good outcomes (48%), 1 case had a fair outcome (4%) and
no patients had poor outcomes. One case relapsed 3 months after surgery and the
recurrence rate was 4%. Postoperative leg pain and lumbar function were
significantly improved with an excellent rate of 96%, which reflects the advantages
of MED, including less trauma and the rapid relief of leg pain (55 Maroon JC, Onik G, Vidovich DV. Percutaneous discectomy for
lumbar disc herniation. Neurosurg Clin N Am.
1993;4(1):125-34.
6 Wang M, Zhou Y, Wang J, Zhang Z, Li C. A 10-year follow-up study
on long-term clinical outcomes of lumbar microendoscopic discectomy.
J Neurol Surg A Cent Eur Neurosurg.
2012;73(4):195-8.-77 Matsumoto M, Watanabe K, Hosogane N, Tsuji T, Ishii K, Nakamura
M, et al. Recurrence of lumbar disc herniation after microendoscopic discectomy.
J Neurol Surg A Cent Eur Neurosurg.
2013;74(4):222-7.,1212 Perez-Cruet MJ, Foley KT, Isaacs RE, Rice-Wyllie L, Wellington
R, Smith MM, et al. Microendoscopic lumbar discectomy: technical note.
Neurosurgery. 2002;51(5 Suppl):129-36.,1717 Kim CH, Chung CK, Jahng TA, Yang HJ, Son YJ. Surgical outcome of
percutaneous endoscopic interlaminar lumbar diskectomy for recurrent disk
herniation after open diskectomy. J Spinal Disord Tech. 2012;25(5):
125-33.
18 Nomura K, Yoshida M, Kawai M, Okada M1, Nakao S. A novel
microendoscopically assisted approach for the treatment of recurrent lumbar disc
herniation: transosseous discectomy surgery. J Neurol Surg A Cent
Eur Neurosurg. 2014;75(3):183-8.
19 Smith JS, Ogden AT, Shafizadeh S, Fessler RG. Clinical outcomes
after microendoscopic discectomy for recurrent lumbar disc herniation.
J Spinal Disord Tech. 2010;23(1):30-4,
http://dx.doi.org/10.1097/BSD.0b013e318193c16c.
http://dx.doi.org/10.1097/BSD.0b013e3181...
20 Koga S, Sairyo K, Shibuya I, Kanamori Y, Kosugi T, Matsumoto H,
et al. Minimally invasive removal of a recurrent lumbar herniated nucleus
pulposus by the small incised microendoscopic discectomy interlaminar approach.
Asian J Endosc Surg. 2012;5(1):34-7.
21 Eloqayli H, Al-omari M. Percutaneous discectomy: minimally
invasive method for treatment of recurrent lumbar disc herniation. Clin Neurol
Neurosurg. 2012;114(7):871-5,
http://dx.doi.org/10.1016/j.clineuro.2012.01.015.
http://dx.doi.org/10.1016/j.clineuro.201...
22 Isaacs RE, Podichetty V, Fessler RG. Microendoscopic discectomy
for recurrent disc herniations. Neurosurg Focus.
2003;15(3):E11.-2323 Lee JK, Amorosa L, Cho SK, Weidenbaum M, Kim Y. Recurrent lumbar
disk herniation. J Am Acad Orthop Surg. 2010;18(6):327-37.).
However, for patients with severe lower back pain, lumbar instability and a severe degenerative intervertebral disc with clear end-plate osteochondritis, we do not recommend this therapy because it may aggravate the symptoms of lower back pain after surgery or induce severe back pain instead of relief. The postoperative imaging supplied evidence demonstrating that the treated intervertebral disc degenerated over time although MED was less invasive. Patients who underwent open surgery to remove the nucleus pulposus with wide exposure in their first surgery have no good indicators; therefore, using MED to treat recurrence is of low value. Based on our inclusion criteria, the outcomes of this study showed that most patients possessed good lumbar function based on postoperative ODI scoring, suggesting that our inclusion criteria were available. Of note, the number of cases in this study was small and this study lacked a comparison with other surgeries. Further design of a multi-center randomized controlled trial may provide some additional convincing evidence.
As long as this technique is applied appropriately and reasonably, MED may represent a good treatment option for recurrent lumbar disc herniation in situ that could avoid the complications of bone graft fusion and cause less trauma compared with open surgery. However, as its operation technique is more difficult, there may be a relatively steep learning curve for surgeons.
This work was supported by The Clinical Great Foundation of Third Military Medical University (2012XLC01).
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No potential conflict of interest was reported.
Publication Dates
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Publication in this collection
Feb 2015
History
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Received
7 Aug 2014 -
Reviewed
29 Aug 2014 -
Accepted
8 Dec 2014