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Comparison of Three Minimally Invasive Spine Surgery Methods for Revision Surgery for Recurrent Herniation After Percutaneous Endoscopic Lumbar Discectomy
Original Article
Comparison of Three Minimally Invasive Spine Surgery Methods for Revision Surgery for Recurrent Herniation After Percutaneous Endoscopic Lumbar Discectomy Yuan Yao1, Huiyu Zhang2, Junlong Wu1, Huan Liu1, Zhengfeng Zhang1, Yu Tang1, Yue Zhou1
BACKGROUND: Patients who experience a recurrence of percutaneous endoscopic lumbar discectomy (PELD) need to undergo revision surgery when they fail to respond to conservative therapy. Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), microendoscopic discectomy (MED), and PELD are 3 common minimally invasive surgical approaches for PELD recurrence. However, there have been no studies that have focused on the selection of the minimally invasive surgical method for PELD recurrence.
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METHODS: Seventy-four patients who underwent revision surgery (MIS-TLIF, 26 cases; MED, 20 cases; PELD, 28 cases) for PELD recurrence were enrolled in this study. The preoperative characteristics and perioperative data were collected. Additionally, the clinical outcomes (visual analogue scale, Oswestry Disability Index, and the 12-item Short Form Health Survey) were collected and assessed at 1, 3, 6, 9, and 12 months postoperatively.
CONCLUSIONS: None of the three surgical approaches exhibited clear advantages in long-term pain or functional scores. MED and PELD were associated with lower costs and better perioperative effects than MIS-TLIF. However, compared with MIS-TLIF, the higher recurrence rates of MED and PELD should not be ignored.
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RESULTS: No significant differences in clinical outcomes over time were observed between these 3 surgical approaches. MED and PELD were associated with greater pain-relief effects at 1 month after surgery than MIS-TLIF, but this effect equalized at 3 months postoperatively. MED and PELD exhibited the advantages of reductions in operation time, blood loss, hospital stay and total cost compared to MIS-TLIF. However, MED and PELD also were significantly associated with greater recurrence rates than MIS-TLIF.
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Key words Percutaneous endoscopic lumbar discectomy - Recurrent herniation - Revision surgery -
Abbreviations and Acronyms MCS: Mental component summary MED: Microendoscopic discectomy MIS-TLIF: Minimally invasive transforaminal lumbar interbody fusion ODI: Oswestry Disability Index PCS: Physical component summary PELD: Percutaneous endoscopic lumbar discectomy RMB: Yuan Renminbi
INTRODUCTION
P
ercutaneous endoscopic lumbar discectomy (PELD) has become a feasible alternative to the conventional open surgery for the treatment of lumbar disc herniation.1 Despite of the merit of minimal invasiveness, the occurrence of recurrent herniation has aroused the concerns of many medical researchers.2,3 The majority of patients suffering from a recurrence of PELD have to undergo revision surgery if the conservative treatment fails to relieve the pain symptoms. Until now, however, no studies have been performed to provide a reference for the selection of the revision surgery for PELD recurrence. It is well known that minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), microendoscopic discectomy (MED), and PELD are 3 common choices for revision surgery for recurrent herniation.4-6 In this study, we compared the outcomes of these 3 minimally invasive spine surgery methods that are used to treat the recurrence of PELD and attempted to explore some helpful insights into the preoperative selection of the revision surgery for the recurrence of PELD.
SF-12: 12-item Short Form Health Survey VAS: visual analogue scale From the 1Department of Orthopedics, Xinqiao Hospital, Third Military Medical University, Chongqing; and 2Department of Stomatology, the 457th Hospital of PLA, Wuhan, China To whom correspondence should be addressed: Yue Zhou, Ph.D., M.D.; Yu Tang, M.D. [E-mail: [email protected]; [email protected]] Supplementary digital content available online. Citation: World Neurosurg. (2017) 100:641-647. http://dx.doi.org/10.1016/j.wneu.2017.01.089 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2017 Elsevier Inc. All rights reserved.
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Table 1. Preoperative Demographic and Clinical Characteristics Characteristics Number of patients Sex: male/female Age, years Marriage: yes/no
MIS-TLIF
MED
PELD
26
20
28
P Value
13/13
11/9
18/10
0.561
51.62 10.04
51.05 16.38
53.68 17.70
0.809
26/0
19/1
27/1
0.548
25.51 4.30
26.42 4.04
25.33 3.96
0.642
Alcohol use: yes/no
4/22
2/18
3/25
0.821
Smoking: yes/no
5/21
2/18
5/23
0.671
Hypertension: yes/no
5/21
3/17
4/24
0.873
Herniation level: L5-S1/L4-L5
8/18
7/13
9/19
0.954
18/10
0.791
13/15
0.281
BMI
Migrated/nonmigrated herniation Modic change: yes/no Paramedian/central herniation
15/11
11/9
7/19
9/11
16/10
12/8
19/9
0.828
VAS (back pain)
5.96 1.15
6.20 1.24
5.86 1.11
0.598
VAS (leg pain)
6.96 1.28
7.35 0.99
7.22 1.00
0.482
ODI
28.0 4.02
29.10 5.17
27.65 4.66
0.576
SF-12 PCS
30.77 6.11
27.25 6.78
29.79 6.82
0.194
SF-12 MCS
24.23 5.08
22.89 5.70
22.05 5.04
0.308
MIS-TLIF, minimally invasive transforaminal lumbar interbody fusion; MED, microendoscopic discectomy; PELD, percutaneous endoscopic lumbar discectomy; BMI, body mass index; VAS, visual analogue scale; ODI, Oswestry Disability Index; SF-12, 12-item Short Form Health Survey; PCS, physical component score; MCS, mental component score.
MATERIALS AND METHODS Patients A series of 3158 patients were treated by PELD for lumbar disc herniation in our hospital from March 2005 to October 2015. Seventy-four patients who suffered from PELD recurrence and underwent reoperation (MIS-TLIF, 26 cases; MED, 20 cases; PELD, 28 cases) were included in this study. All the study procedures were approved by the Ethics Committee of Xinqiao Hospital, Third Military Medical University and were conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants. The indications for surgery were as follows. 1) The patient met the criteria for PELD recurrence (i.e., the patient had undergone a successful PELD as confirmed by a pain-free period of at least 1 month, there were recurrent symptoms of pain, and an magnetic resonance imaging scan confirmation of a reherniated fragment on the same level as the previous PELD surgery was achieved). 2) Conservative therapy failed to relieve the recurrent pain. The selection of MIS-TLIF is recommended in the cases of vertebral instability or spondylolisthesis. With the exception of the aforementioned conditions, for pure herniation, no definite inclusion or exclusion criteria for these 3 surgical methods (i.e., MIS-TLIF, MED, and PELD) have been reported. Thus, in principle, these 3 surgical methods are considered suitable for all patients without vertebral instability or spondylolisthesis. Actually, in this study, there were no patients who exhibited vertebral
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instability or spondylolisthesis. Therefore, we believe each of included patients was appropriate for each of these 3 surgical methods. Full disclosure of all the surgical details, including the surgical procedures, total cost, experience of the surgeons, complications, and possible therapeutic effects, was provided to the patients, and the final selections were made by the patients. Clinical Assessment The preoperative data from all the enrolled patients were assessed in terms of demographic data (i.e., sex, age, marital status, body mass index, alcohol use history, smoking history, and hypertension history) and clinical data (i.e., herniation level, migrated/nonmigrated herniation, Modic change, and paramedian/central herniation). Every enrolled participant was asked to complete a questionnaire that included visual analogue scales (VAS) for both low back pain and leg pain, the Oswestry Disability Index (ODI), and the 12-item Short-Form Health Survey (SF-12, which consists of a physical component summary [PCS] and a mental component summary [MCS]) preoperatively and at each time point of the follow-up visits. The follow-up visits were performed at the time points of 1, 3, 6, 9, and 12 months postoperatively. The patients received and returned the questionnaire via e-mail or mail and were contacted by telephone if necessary. In addition, the perioperative conditions (i.e., operation time, blood loss, and hospital stay), cost, complications, and recurrence condition also were collected and evaluated.
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Figure 1. Pain and functional scores of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), microendoscopic diskectomy (MED), and percutaneous endoscopic lumbar discectomy (PELD) at different time points. P indicates the statistical difference among the 3 surgical methods
Surgical Techniques MIS-TLIF was performed as described by Foley et al.7 with a Quadrant Retractor System and a Sextant percutaneous pedicle screw system (Medtronic Sofamor Danek, Memphis, Tennessee, USA). MED was performed as described by Perez-Cruet et al.8 with the METRx endoscopic system (Medtronic Sofamor Danek). PELD was performed as described by Hoogland et al.9 and Yeung and Tsou10 via the transforaminal endoscopic spine system (Joinmax, Karlsruhe, Germany). Statistical Analysis The data are given as the means the standard deviations. The changes in the clinical parameters (VAS, ODI, and SF-12 PCS/MCS) over time in each of the 3 groups were identified via repeated-measures analysis of variance. One-way analysis of variance was used to confirm the differences between the 3 groups. To evaluate the improvements at each follow-up time point, the preoperative pain and functional scores were considered as the baselines, and improvements were then calculated as the differences between the follow-up measures and the baselines. c2 tests were performed to compare categorical variables among the 3 groups. Significance was set at a P value of <0.05. All data analyses were performed with SPSS 16.0 (SPSS, Chicago, Illinois, USA).
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over time. VAS, visual analogue scale; ODI, Oswestry Disability Index; SF-12, 12-item Short Form Health Survey; PCS, physical component score; MCS, mental component score.
RESULTS Preoperative Demographic and Clinical Characteristics We reviewed 74 patients (MIS-TLIF, 26 cases; MED, 20 cases; PELD, 28 cases) who met the inclusion criteria. The preoperative demographic and clinical characteristics were not significantly different between the 3 groups (Table 1). Clinical Outcomes Generally, there were no significant differences in the preoperative pain levels or functional scores between the 3 groups (Table 1). At 1 month postoperatively, the scores were decreased significantly in all 3 groups compared with the scores before surgery. In addition, there were no significant differences between the 3 groups for any of the scores over time (VAS-back pain, P ¼ 0.679; VAS-leg pain, P ¼ 0.211; ODI, P ¼ 0.207; SF-12 PCS, P ¼ 0.384; SF-12 MCS, P ¼ 0.670; Figure 1). The improvement of the VAS scores for back pain in MIS-TLIF group (2.65 1.29) was significantly lower than those in both the MED (3.60 1.54, P ¼ 0.024) and PELD groups (3.61 1.44, P ¼ 0.013) at 1 month after surgery. At 12 months after the surgery, however, the improvement of the VAS scores for back pain in the MIS-TLIF group (3.92 1.38) was significantly greater than that in the PELD group (3.00 1.48, P ¼ 0.037). The patients in the MED
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Table 2. Clinical Improvement According to the Parameters Difference at Each Time Point Parameters
MIS-TLIF
MED
PELD
Total Rate
MIS-TLIF versus MED
MIS-TLIF versus PELD
MED versus PELD
2.65 1.29
3.60 1.54
3.61 1.44
0.023*
0.024*
0.013*
0.986
VAS (back) 1 month 3 months
3.77 1.58
4.05 1.51
3.42 1.55
0.402
0.547
0.424
0.184
6 months
4.27 1.48
4.05 1.66
3.70 1.22
0.388
0.633
0.172
0.434
9 months
4.00 1.50
4.17 1.34
3.39 1.44
0.182
0.706
0.144
0.091
12 months
3.92 1.38
3.94 1.73
3.00 1.48
0.065
0.093
0.037*
0.052
VAS (leg) 1 month
4.38 1.53
4.15 1.23
3.68 1.49
0.193
0.585
0.076
0.267
3 months
4.58 1.32
5.26 1.33
5.46 1.48
0.270
0.320
0.113
0.635
6 months
5.00 1.57
5.50 1.20
5.35 1.11
0.438
0.226
0.365
0.718
9 months
5.42 1.68
5.06 1.11
5.26 1.14
0.682
0.384
0.680
0.635
12 months
5.38 1.53
5.39 1.29
4.78 1.00
0.205
0.991
0.111
0.144
12.92 3.72
16.50 7.31
13.50 5.24
0.072
0.030*
0.698
0.064
ODI 1 month 3 months
15.15 3.26
17.26 5.70
14.31 5.11
0.116
0.142
0.519
0.041
6 months
15.69 4.69
17.56 6.67
16.87 6.84
0.585
0.318
0.499
0.719
9 months
16.23 3.97
15.89 6.84
16.26 6.07
0.974
0.843
0.985
0.833
12 months
16.00 4.38
15.33 7.00
16.26 5.27
0.861
0.693
0.868
0.593
12.75 9.52
13.39 8.50
0.006*
0.012*
0.003*
0.816
SF12-PCS 1 month
5.58 10.13
3 months
10.58 8.52
13.95 9.06
14.23 11.02
0.335
0.251
0.177
0.923
6 months
14.42 11.94
18.33 10.98
17.39 11.66
0.496
0.276
0.375
0.797
9 months
18.27 10.67
20.28 10.91
16.74 8.87
0.545
0.521
0.600
0.272
12 months
18.65 12.21
18.61 9.82
14.35 9.81
0.311
0.990
0.169
0.215
1 month
6.30 7.81
12.39 9.29
11.70 6.99
0.016*
0.012*
0.015*
0.768
3 months
12.28 9.27
12.16 7.12
15.18 7.98
0.354
0.962
0.209
0.230
SF12-MCS
6 months
17.12 10.69
15.40 9.22
18.44 8.08
0.596
0.555
0.628
0.311
9 months
16.96 7.65
17.03 9.16
17.17 7.80
0.996
0.977
0.931
0.959
12 months
17.28 9.53
17.03 6.68
16.98 7.86
0.991
0.921
0.899
0.985
MIS-TLIF, minimally invasive transforaminal lumbar interbody fusion; MED, microendoscopic discectomy; PELD, percutaneous endoscopic lumbar discectomy; VAS, visual analogue scale; ODI, Oswestry Disability Index; SF-12, 12-item Short Form Health Survey; PCS, physical component summary; MCS, mental component summary. *Statistically significant differences.
group (16.50 7.31) exhibited a greater improvement in the ODI score than did the patients in the MIS-TLIF group (12.92 3.72, P ¼ 0.030) at 1 month after surgery. In terms of the SF-12 PCS/MCS scores, the patients in MIS-TLIF group (PCS, 5.58 10.13; MCS, 6.30 7.81) exhibited poorer improvement than did those in both the MED (PCS, 12.75 9.52, P ¼ 0.012;
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MCS, 12.39 9.29, P ¼ 0.012) and PELD groups (PCS, 13.39 8.50, P ¼ 0.003; MCS, 11.70 6.99, P ¼ 0.015; Table 2). Perioperative Outcomes and Cost The operation time in the MIS-TLIF group (146.54 38.07 minutes) was significantly longer than those in the MED group
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Table 3. Summary of Perioperative Outcomes, Cost, Complication, and Recurrence MIS-TLIF
MED
PELD
P Value
Operation time, minutes
146.54 38.07
85.25 41.60
75.00 31.56
<0.001* <0.001y <0.001z 0.344x
Blood loss, mL
148.46 74.76
Not measurable
Not measurable
14.96 5.36
8.75 2.22
8.86 3.34
<0.001* <0.001y <0.001z 0.927x
67913.65 14395.18
18005.65 8159.06
15817.25 5055.67
<0.001* <0.001y <0.001z 0.458x
1 (3.85)
2 (10.00)
4 (14.29)
0.422*
0 (0)
3 (15.00)
7 (25.00)
0.026* 0.631x 0.024k
Hospital stay, days
Total cost, RMB
Complications, n (%) Recurrence, n (%)
MIS-TLIF, minimally invasive transforaminal lumbar interbody fusion; MED, microendoscopic discectomy; PELD, percutaneous endoscopic lumbar discectomy; RMB, Yuan Renminbi. *Difference of total rate. yDifference between MIS-TLIF group and MED group. zDifference between MIS-TLIF group and PELD group. xDifference between MED group and PELD group. kDifference between MIS-TLIF group and (MED þ PELD) group.
(85.25 41.60 minutes, P < 0.001) and PELD groups (75.00 31.56 minutes, P < 0.001). In addition, there was no significant difference in the operation time between the MED and PELD groups (P ¼ 0.344). There was no measurable blood loss in either the MED or PELD groups, and the intraoperative blood loss was 148.46 74.76 mL in the MIS-TLIF group. The hospital stay in the MIS-TLIF group (14.96 5.36 days) was significantly longer than those in the MED (8.75 2.22 days, P < 0.001) and PELD groups (8.86 3.34 days, P < 0.001). There was no significant difference in hospital stay between the MED and PELD groups (P ¼ 0.927). The total cost in the MIS-TLIF group (67,913.65 14,395.18 Yuan Renminbi [RMB]) was significantly greater than the costs in the MED (18,005.65 8159.06 RMB, P < 0.001) and PELD groups (15,817.25 5055.67 RMB, P < 0.001). There also was no significant difference in the hospital stay between the MED and PELD groups (P ¼ 0.458; Table 3). Operation Complications and Recurrences Complications occurred in 1 patient (3.85%) in the MIS-TLIF group, 2 patients (10.00%) in the MED group, and 4 patients (14.29%) in the PELD group. One patient in the MIS-TLIF group suffered an incidental durotomy. Two patients in the MED group and 2 patients in the PELD group experienced dysesthesia after surgery. Two patients in the PELD group (one was a 67-year-old man, and the other was a 62-year-old man; the bottle
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containing normal saline was hung 1.2 m greater than the level of patient to provide irrigation pressure) experienced headache intraoperatively, and they both improved at 1 day postoperatively with sufficient bed rest. No significant differences in the complication rates were observed between the 3 groups (P ¼ 0.422). During the follow-up period, no patients in the MIS-TLIF group (0.00%), 3 patients in the MED group (15.00%), and 7 patients in the PELD group (25.00%) suffered from recurrence (information about patients who experienced re-recurrence can be found in Supplementary Table 1). The recurrence rate of the patients in the MIS-TLIF group was significantly lower than those in the MED and PELD groups (P ¼ 0.024; Table 3). DISCUSSION The recurrence rate after PELD has been reported to be 0%e7.4%.1,9,11,12 Revision surgery is necessary for patients who fail to respond to conservative therapy. No study, however, has focused on the selection of the revision surgery method for the recurrence of PELD. It is well known that recurrent herniation is regarded as a major indication for TLIF or repeated discectomy.13,14 Currently, MIS-TLIF and MED/PELD are considered as commendable alternatives to open TLIF and discectomy.15-17 In the present study, we compared the outcomes of these 3 operation methods for PELD recurrence and sought to provide a reference for the selection of revision surgery.
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Comparison of the Clinical Outcomes Generally, all the pain and functional parameters were improved significantly postoperatively compared with the baseline levels before the surgeries in the 3 groups. These favorable outcomes are consistent with the results of previous studies.15-17 In addition, there were no significant differences between the 3 groups for any of the scores over time. The back pain-relief effect in the MIS-TLIF group was worse than that in the nonfusion group (MED/PELD) at 1 month after surgery. This result may be due to the relatively larger injury incurred during interbody fusion compared with discectomy. At the time point of 1 month after surgery, the patients experienced more predominant back pain than leg pain for the fusion versus discectomy procedures. We believe that the leg pain was caused by nerve compression, which can obviously be relieved by either fusion or discectomy. The relatively larger injury to the paravertebral tissue caused by fusion surgery compared with diskectomy, however, may lead to more back pain (vs. discectomy) in the short term after surgery. At the time point of 12 months after surgery, the patients experienced more predominant back pain in the PELD group than in the MIS-TLIF group, and there was no significant difference in the leg pain scores between the 2 groups. We believe these findings can be explained by the greater tendency towards spinal instability and re-recurrence after PELD (re-recurrence rate: 25%) compared with MIS-TLIF (re-recurrence rate: 0%). Given that the follow-up period in this study was relatively short (12 months), back pain may only be the initial symptom, and it will be necessary to follow this patient cohort for a longer period to determine whether the difference in leg pain symptoms will reappear. A reduction of the ODI score of 15 points could reflect clinical improvement.18 The SF-12 PCS/MCS scores were used to assess the health-related quality of life.19 Both the ODI and SF-12 PCS/MCS scores exhibited trends that were similar to that of the VAS scores, indicating that the clinical status and quality of life were highly involved with the pain level.
and the working channel might compress the exiting root intraoperatively; thus, a prolonged operation time would contribute to nerve irritation.23 Therefore, we believe that these complications observed in our study were all associated with difficulties in manipulation. The potential reasons for these difficulties may be as follows: 1) the inherent difficulties of revision surgery, such as scar formation and the distorted anatomical landmarks, make the procedure more technically demanding than the primary surgery; and 2) the learning curves for minimally invasive surgical techniques are steep. Therefore, we believe that revision surgeries for PELD recurrence should be assigned to experienced surgeons for the safety of the patients, and novice surgeons should receive sufficient training. There were no patients in the MIS-TLIF group, 3 patients in the MED group, and 7 patients in the PELD group who suffered from recurrent herniation. The recurrence rate among the patients in the MIS-TLIF group was significantly lower than the rates in the nonfusion groups. The reasons for these findings may be as follows. 1) There were some common risk factors that were predictive of recurrence in both the MED and PELD groups. For example, old age, obesity, and Modic change have been reported to be risk factors for both MED recurrence and PELD recurrence.3,24 The participants who experienced recurrence after revision surgery were either older (60 years old) or obese (body mass index 25), and these patients were at high risk for recurrent herniation after either MED or PELD. The risk factors for recurrence after the primary surgery also might predict recurrence after the secondary surgery. 2) After the primary PELD surgery, the artificial incision in the annulus fibrosus could alter the interlaminar shear stress and make the annulus fibrosus more prone to delamination. Consequently, recurrent herniations tend to form based on the damage to the annulus fibrosus.25 Therefore, MED or PELD may be not able to effectively solve this problem, and thorough interbody fusion (MIS-TLIF) might be a better selection.
Comparison of the Perioperative Outcomes and Cost Consistent with previous studies, the operation times, hospital stays, blood losses, and total costs for the patients in the MED and PELD groups were significantly lower than those of the MIS-TLIF group.15-17 Although the relationships between these parameters and the health of the patients are uncertain, these factors may influence the patients’ mental health to some extent.
Limitations It is necessary to note that the present study has some limitations. 1) It was a retrospective study. 2) The sample size was small (MIS-TLIF, n ¼ 26; MED, n ¼ 20; PELD, n ¼ 28). 3) The follow-up period was short (12 months), and some diseases (such as adjacent segment disease) can only be observed after a longer followup period. A prospective randomized controlled trial with a larger sample size and a longer follow-up period is necessary to provide more helpful information about the assessments of these 3 surgical methods for PELD recurrence.
Comparison of Complications and Recurrences In this study, 1 patient in the MIS-TLIF group experienced an incidental durotomy, which is a common complication of revision spinal surgery.20,21 The occurrence of incidental durotomy is associated with the proficiency of the use of tubular retractors. The limited visual field increases the operational difficulties. In addition, 2 patients in MED group and 2 patients in PELD group experienced postoperative dysaesthesia, and 2 patients in PELD group experienced intraoperative headache. These complications also might be strongly related to the surgeon’s proficiency in the operation. Previous studies have reported that the intracranial pressure increases if the endoscopic operation time is too long,22
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CONCLUSIONS In this study, the outcomes of MIS-TLIF, MED, and PELD as revision surgeries for PELD recurrence were compared. Generally, there were no significant differences in the clinical outcomes over time between these 3 operation methods. MED and PELD were associated with greater pain relief at 1 month after surgery compared with MIS-TLIF, but this effect was neutralized at 3 months postoperatively. MED and PELD
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exhibited advantages in terms of reductions in operation time, blood loss, hospital stay, and total cost compared with MIS-TLIF. However, MED and PELD also were significantly associated with greater recurrence rates compared with MIS-TLIF. Thus, when evaluating a minimally invasive revision surgery for PELD recurrence, the advantages should be
REFERENCES 1. Ruetten S, Komp M, Merk H, Godolias G. Fullendoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study. Spine (Phila Pa 1976). 2008;33:931-939. 2. Cheng J, Wang H, Zheng W, Li C, Wang J, Zhang Z, et al. Reoperation after lumbar disc surgery in two hundred and seven patients. Int Orthop. 2013;37:1511-1517. 3. Kim JM, Lee SH, Ahn Y, Yoon DH, Lee CD, Lim ST. Recurrence after successful percutaneous endoscopic lumbar discectomy. Minim Invasive Neurosurg. 2007;50:82-85. 4. Ahn Y, Lee SH, Park WM, Lee HY, Shin SW, Kang HY. Percutaneous endoscopic lumbar discectomy for recurrent disc herniation: surgical technique, outcome, and prognostic factors of 43 consecutive cases. Spine (Phila Pa 1976). 2004;29: E326-E332. 5. Smith JS, Ogden AT, Shafizadeh S, Fessler RG. Clinical outcomes after microendoscopic discectomy for recurrent lumbar disc herniation. J Spinal Disord Tech. 2010;23:30-34. 6. Wang J, Zhou Y, Zhang ZF, Li CQ, Zheng WJ, Liu J. Minimally invasive or open transforaminal lumbar interbody fusion as revision surgery for patients previously treated by open discectomy and decompression of the lumbar spine. Eur Spine J. 2011;20:623-628. 7. Foley KT, Holly LT, Schwender JD. Minimally invasive lumbar fusion. Spine (Phila Pa 1976). 2003; 28:S26-S35. 8. Perez-Cruet MJ, Foley KT, Isaacs RE, RiceWyllie L, Wellington R, Smith MM, et al. Microendoscopic lumbar discectomy: technical note. Neurosurgery. 2002;51:S129-S136. 9. Hoogland T, Schubert M, Miklitz B, Ramirez A. Transforaminal posterolateral endoscopic discectomy with or without the combination of a low-dose chymopapain: a prospective randomized study in 280 consecutive cases. Spine (Phila Pa 1976). 2006;31:E890-E897.
carefully weighed against the potential disadvantages, and the patients should be informed fully. ACKNOWLEDGMENTS We thank Yangyi Zheng for the collection of data.
10. Yeung AT, Tsou PM. Posterolateral endoscopic excision for lumbar disc herniation: Surgical technique, outcome, and complications in 307 consecutive cases. Spine (Phila Pa 1976). 2002;27: 722-731. 11. Choi KC, Kim JS, Kang BU, Lee CD, Lee SH. Changes in back pain after percutaneous endoscopic lumbar discectomy and annuloplasty for lumbar disc herniation: a prospective study. Pain Med. 2011;12:1615-1621. 12. Jang JS, An SH, Lee SH. Transforaminal percutaneous endoscopic discectomy in the treatment of foraminal and extraforaminal lumbar disc herniations. J Spinal Disord Tech. 2006;19:338-343. 13. El SA, El WM, Morsi AM. Recurrent lumbar disc herniation: a prospective comparative study of three surgical management procedures. Asian J Neurosurg. 2013;8:139-146. 14. 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;31:1473-1476. 15. Ahn SS, Kim SH, Kim DW, Lee BH. Comparison of outcomes of percutaneous endoscopic lumbar discectomy and open lumbar microdiscectomy for young adults: a retrospective matched cohort study. World Neurosurg. 2016;86:250-258. 16. Parker SL, Mendenhall SK, Shau DN, Zuckerman SL, Godil SS, Cheng JS, et al. Minimally invasive versus open transforaminal lumbar interbody fusion for degenerative spondylolisthesis: comparative effectiveness and cost-utility analysis. World Neurosurg. 2014;82:230-238. 17. Wu X, Zhuang S, Mao Z, Chen H. Microendoscopic discectomy for lumbar disc herniation: surgical technique and outcome in 873 consecutive cases. Spine (Phila Pa 1976). 2006;31: 2689-2694. 18. Deutsch H. The predictive value of the baseline Oswestry Disability Index in lumbar disc arthroplasty. Neurosurg Focus. 2010;28:E7.
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19. Lam CL, Tse EY, Gandek B. Is the standard SF-12 health survey valid and equivalent for a Chinese population? Qual Life Res. 2005;14:539-547. 20. Cammisa FJ, Girardi FP, Sangani PK, Parvataneni HK, Cadag S, Sandhu HS. Incidental durotomy in spine surgery. Spine (Phila Pa 1976). 2000;25:2663-2667. 21. Wang JC, Bohlman HH, Riew KD. Dural tears secondary to operations on the lumbar spine. Management and results after a two-yearminimum follow-up of eighty-eight patients. J Bone Joint Surg Am. 1998;80:1728-1732. 22. Sairyo K, Matsuura T, Higashino K, Sakai T, Takata Y, Goda Y, et al. Surgery related complications in percutaneous endoscopic lumbar discectomy under local anesthesia. J Med Invest. 2014; 61:264-269. 23. Choi I, Ahn JO, So WS, Lee SJ, Choi IJ, Kim H. Exiting root injury in transforaminal endoscopic discectomy: preoperative image considerations for safety. Eur Spine J. 2013;22:2481-2487. 24. Yao Y, Liu H, Zhang H, Wang H, Zhang Z, Zheng Y, et al. Risk factors for the recurrent herniation after microendoscopic discectomy. World Neurosurg. 2016;95:451-455. 25. Iatridis JC, Ap GI. Mechanisms for mechanical damage in the intervertebral disc annulus fibrosus. J Biomech. 2004;37:1165-1175.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 29 October 2016; accepted 23 January 2017 Citation: World Neurosurg. (2017) 100:641-647. http://dx.doi.org/10.1016/j.wneu.2017.01.089 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2017 Elsevier Inc. All rights reserved.
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SUPPLEMENTARY DATA
Supplementary Table 1. Information of Patients with Re-recurrence Number of Patients
Revision Surgery Methods
1
MED
Male
76
27.83
2
MED
Female
74
26.56
3
MED
Male
56
31.60
4
PELD
Female
68
22.40
5
PELD
Female
45
28.03
6
PELD
Female
48
29.06
7
PELD
Female
41
26.80
8
PELD
Male
58
27.62
9
PELD
Male
56
31.60
10
PELD
Female
65
34.13
Sex
Age, years
BMI
BMI, body mass index; MED, microendoscopic discectomy; PELD, percutaneous endoscopic lumbar discectomy.
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WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2017.01.089
Comparison of Three Minimally Invasive Spine Surgery Methods for Revision Surgery for Recurrent Herniation After Percutaneous Endoscopic Lumbar Discectomy Yuan Yao1, Huiyu Zhang2, Junlong Wu1, Huan Liu1, Zhengfeng Zhang1, Yu Tang1, Yue Zhou1
BACKGROUND: Patients who experience a recurrence of percutaneous endoscopic lumbar discectomy (PELD) need to undergo revision surgery when they fail to respond to conservative therapy. Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), microendoscopic discectomy (MED), and PELD are 3 common minimally invasive surgical approaches for PELD recurrence. However, there have been no studies that have focused on the selection of the minimally invasive surgical method for PELD recurrence.
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METHODS: Seventy-four patients who underwent revision surgery (MIS-TLIF, 26 cases; MED, 20 cases; PELD, 28 cases) for PELD recurrence were enrolled in this study. The preoperative characteristics and perioperative data were collected. Additionally, the clinical outcomes (visual analogue scale, Oswestry Disability Index, and the 12-item Short Form Health Survey) were collected and assessed at 1, 3, 6, 9, and 12 months postoperatively.
CONCLUSIONS: None of the three surgical approaches exhibited clear advantages in long-term pain or functional scores. MED and PELD were associated with lower costs and better perioperative effects than MIS-TLIF. However, compared with MIS-TLIF, the higher recurrence rates of MED and PELD should not be ignored.
-
-
RESULTS: No significant differences in clinical outcomes over time were observed between these 3 surgical approaches. MED and PELD were associated with greater pain-relief effects at 1 month after surgery than MIS-TLIF, but this effect equalized at 3 months postoperatively. MED and PELD exhibited the advantages of reductions in operation time, blood loss, hospital stay and total cost compared to MIS-TLIF. However, MED and PELD also were significantly associated with greater recurrence rates than MIS-TLIF.
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Key words Percutaneous endoscopic lumbar discectomy - Recurrent herniation - Revision surgery -
Abbreviations and Acronyms MCS: Mental component summary MED: Microendoscopic discectomy MIS-TLIF: Minimally invasive transforaminal lumbar interbody fusion ODI: Oswestry Disability Index PCS: Physical component summary PELD: Percutaneous endoscopic lumbar discectomy RMB: Yuan Renminbi
INTRODUCTION
P
ercutaneous endoscopic lumbar discectomy (PELD) has become a feasible alternative to the conventional open surgery for the treatment of lumbar disc herniation.1 Despite of the merit of minimal invasiveness, the occurrence of recurrent herniation has aroused the concerns of many medical researchers.2,3 The majority of patients suffering from a recurrence of PELD have to undergo revision surgery if the conservative treatment fails to relieve the pain symptoms. Until now, however, no studies have been performed to provide a reference for the selection of the revision surgery for PELD recurrence. It is well known that minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), microendoscopic discectomy (MED), and PELD are 3 common choices for revision surgery for recurrent herniation.4-6 In this study, we compared the outcomes of these 3 minimally invasive spine surgery methods that are used to treat the recurrence of PELD and attempted to explore some helpful insights into the preoperative selection of the revision surgery for the recurrence of PELD.
SF-12: 12-item Short Form Health Survey VAS: visual analogue scale From the 1Department of Orthopedics, Xinqiao Hospital, Third Military Medical University, Chongqing; and 2Department of Stomatology, the 457th Hospital of PLA, Wuhan, China To whom correspondence should be addressed: Yue Zhou, Ph.D., M.D.; Yu Tang, M.D. [E-mail: [email protected]; [email protected]] Supplementary digital content available online. Citation: World Neurosurg. (2017) 100:641-647. http://dx.doi.org/10.1016/j.wneu.2017.01.089 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2017 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY 100: 641-647, APRIL 2017
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Table 1. Preoperative Demographic and Clinical Characteristics Characteristics Number of patients Sex: male/female Age, years Marriage: yes/no
MIS-TLIF
MED
PELD
26
20
28
P Value
13/13
11/9
18/10
0.561
51.62 10.04
51.05 16.38
53.68 17.70
0.809
26/0
19/1
27/1
0.548
25.51 4.30
26.42 4.04
25.33 3.96
0.642
Alcohol use: yes/no
4/22
2/18
3/25
0.821
Smoking: yes/no
5/21
2/18
5/23
0.671
Hypertension: yes/no
5/21
3/17
4/24
0.873
Herniation level: L5-S1/L4-L5
8/18
7/13
9/19
0.954
18/10
0.791
13/15
0.281
BMI
Migrated/nonmigrated herniation Modic change: yes/no Paramedian/central herniation
15/11
11/9
7/19
9/11
16/10
12/8
19/9
0.828
VAS (back pain)
5.96 1.15
6.20 1.24
5.86 1.11
0.598
VAS (leg pain)
6.96 1.28
7.35 0.99
7.22 1.00
0.482
ODI
28.0 4.02
29.10 5.17
27.65 4.66
0.576
SF-12 PCS
30.77 6.11
27.25 6.78
29.79 6.82
0.194
SF-12 MCS
24.23 5.08
22.89 5.70
22.05 5.04
0.308
MIS-TLIF, minimally invasive transforaminal lumbar interbody fusion; MED, microendoscopic discectomy; PELD, percutaneous endoscopic lumbar discectomy; BMI, body mass index; VAS, visual analogue scale; ODI, Oswestry Disability Index; SF-12, 12-item Short Form Health Survey; PCS, physical component score; MCS, mental component score.
MATERIALS AND METHODS Patients A series of 3158 patients were treated by PELD for lumbar disc herniation in our hospital from March 2005 to October 2015. Seventy-four patients who suffered from PELD recurrence and underwent reoperation (MIS-TLIF, 26 cases; MED, 20 cases; PELD, 28 cases) were included in this study. All the study procedures were approved by the Ethics Committee of Xinqiao Hospital, Third Military Medical University and were conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants. The indications for surgery were as follows. 1) The patient met the criteria for PELD recurrence (i.e., the patient had undergone a successful PELD as confirmed by a pain-free period of at least 1 month, there were recurrent symptoms of pain, and an magnetic resonance imaging scan confirmation of a reherniated fragment on the same level as the previous PELD surgery was achieved). 2) Conservative therapy failed to relieve the recurrent pain. The selection of MIS-TLIF is recommended in the cases of vertebral instability or spondylolisthesis. With the exception of the aforementioned conditions, for pure herniation, no definite inclusion or exclusion criteria for these 3 surgical methods (i.e., MIS-TLIF, MED, and PELD) have been reported. Thus, in principle, these 3 surgical methods are considered suitable for all patients without vertebral instability or spondylolisthesis. Actually, in this study, there were no patients who exhibited vertebral
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instability or spondylolisthesis. Therefore, we believe each of included patients was appropriate for each of these 3 surgical methods. Full disclosure of all the surgical details, including the surgical procedures, total cost, experience of the surgeons, complications, and possible therapeutic effects, was provided to the patients, and the final selections were made by the patients. Clinical Assessment The preoperative data from all the enrolled patients were assessed in terms of demographic data (i.e., sex, age, marital status, body mass index, alcohol use history, smoking history, and hypertension history) and clinical data (i.e., herniation level, migrated/nonmigrated herniation, Modic change, and paramedian/central herniation). Every enrolled participant was asked to complete a questionnaire that included visual analogue scales (VAS) for both low back pain and leg pain, the Oswestry Disability Index (ODI), and the 12-item Short-Form Health Survey (SF-12, which consists of a physical component summary [PCS] and a mental component summary [MCS]) preoperatively and at each time point of the follow-up visits. The follow-up visits were performed at the time points of 1, 3, 6, 9, and 12 months postoperatively. The patients received and returned the questionnaire via e-mail or mail and were contacted by telephone if necessary. In addition, the perioperative conditions (i.e., operation time, blood loss, and hospital stay), cost, complications, and recurrence condition also were collected and evaluated.
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Figure 1. Pain and functional scores of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), microendoscopic diskectomy (MED), and percutaneous endoscopic lumbar discectomy (PELD) at different time points. P indicates the statistical difference among the 3 surgical methods
Surgical Techniques MIS-TLIF was performed as described by Foley et al.7 with a Quadrant Retractor System and a Sextant percutaneous pedicle screw system (Medtronic Sofamor Danek, Memphis, Tennessee, USA). MED was performed as described by Perez-Cruet et al.8 with the METRx endoscopic system (Medtronic Sofamor Danek). PELD was performed as described by Hoogland et al.9 and Yeung and Tsou10 via the transforaminal endoscopic spine system (Joinmax, Karlsruhe, Germany). Statistical Analysis The data are given as the means the standard deviations. The changes in the clinical parameters (VAS, ODI, and SF-12 PCS/MCS) over time in each of the 3 groups were identified via repeated-measures analysis of variance. One-way analysis of variance was used to confirm the differences between the 3 groups. To evaluate the improvements at each follow-up time point, the preoperative pain and functional scores were considered as the baselines, and improvements were then calculated as the differences between the follow-up measures and the baselines. c2 tests were performed to compare categorical variables among the 3 groups. Significance was set at a P value of <0.05. All data analyses were performed with SPSS 16.0 (SPSS, Chicago, Illinois, USA).
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over time. VAS, visual analogue scale; ODI, Oswestry Disability Index; SF-12, 12-item Short Form Health Survey; PCS, physical component score; MCS, mental component score.
RESULTS Preoperative Demographic and Clinical Characteristics We reviewed 74 patients (MIS-TLIF, 26 cases; MED, 20 cases; PELD, 28 cases) who met the inclusion criteria. The preoperative demographic and clinical characteristics were not significantly different between the 3 groups (Table 1). Clinical Outcomes Generally, there were no significant differences in the preoperative pain levels or functional scores between the 3 groups (Table 1). At 1 month postoperatively, the scores were decreased significantly in all 3 groups compared with the scores before surgery. In addition, there were no significant differences between the 3 groups for any of the scores over time (VAS-back pain, P ¼ 0.679; VAS-leg pain, P ¼ 0.211; ODI, P ¼ 0.207; SF-12 PCS, P ¼ 0.384; SF-12 MCS, P ¼ 0.670; Figure 1). The improvement of the VAS scores for back pain in MIS-TLIF group (2.65 1.29) was significantly lower than those in both the MED (3.60 1.54, P ¼ 0.024) and PELD groups (3.61 1.44, P ¼ 0.013) at 1 month after surgery. At 12 months after the surgery, however, the improvement of the VAS scores for back pain in the MIS-TLIF group (3.92 1.38) was significantly greater than that in the PELD group (3.00 1.48, P ¼ 0.037). The patients in the MED
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Table 2. Clinical Improvement According to the Parameters Difference at Each Time Point Parameters
MIS-TLIF
MED
PELD
Total Rate
MIS-TLIF versus MED
MIS-TLIF versus PELD
MED versus PELD
2.65 1.29
3.60 1.54
3.61 1.44
0.023*
0.024*
0.013*
0.986
VAS (back) 1 month 3 months
3.77 1.58
4.05 1.51
3.42 1.55
0.402
0.547
0.424
0.184
6 months
4.27 1.48
4.05 1.66
3.70 1.22
0.388
0.633
0.172
0.434
9 months
4.00 1.50
4.17 1.34
3.39 1.44
0.182
0.706
0.144
0.091
12 months
3.92 1.38
3.94 1.73
3.00 1.48
0.065
0.093
0.037*
0.052
VAS (leg) 1 month
4.38 1.53
4.15 1.23
3.68 1.49
0.193
0.585
0.076
0.267
3 months
4.58 1.32
5.26 1.33
5.46 1.48
0.270
0.320
0.113
0.635
6 months
5.00 1.57
5.50 1.20
5.35 1.11
0.438
0.226
0.365
0.718
9 months
5.42 1.68
5.06 1.11
5.26 1.14
0.682
0.384
0.680
0.635
12 months
5.38 1.53
5.39 1.29
4.78 1.00
0.205
0.991
0.111
0.144
12.92 3.72
16.50 7.31
13.50 5.24
0.072
0.030*
0.698
0.064
ODI 1 month 3 months
15.15 3.26
17.26 5.70
14.31 5.11
0.116
0.142
0.519
0.041
6 months
15.69 4.69
17.56 6.67
16.87 6.84
0.585
0.318
0.499
0.719
9 months
16.23 3.97
15.89 6.84
16.26 6.07
0.974
0.843
0.985
0.833
12 months
16.00 4.38
15.33 7.00
16.26 5.27
0.861
0.693
0.868
0.593
12.75 9.52
13.39 8.50
0.006*
0.012*
0.003*
0.816
SF12-PCS 1 month
5.58 10.13
3 months
10.58 8.52
13.95 9.06
14.23 11.02
0.335
0.251
0.177
0.923
6 months
14.42 11.94
18.33 10.98
17.39 11.66
0.496
0.276
0.375
0.797
9 months
18.27 10.67
20.28 10.91
16.74 8.87
0.545
0.521
0.600
0.272
12 months
18.65 12.21
18.61 9.82
14.35 9.81
0.311
0.990
0.169
0.215
1 month
6.30 7.81
12.39 9.29
11.70 6.99
0.016*
0.012*
0.015*
0.768
3 months
12.28 9.27
12.16 7.12
15.18 7.98
0.354
0.962
0.209
0.230
SF12-MCS
6 months
17.12 10.69
15.40 9.22
18.44 8.08
0.596
0.555
0.628
0.311
9 months
16.96 7.65
17.03 9.16
17.17 7.80
0.996
0.977
0.931
0.959
12 months
17.28 9.53
17.03 6.68
16.98 7.86
0.991
0.921
0.899
0.985
MIS-TLIF, minimally invasive transforaminal lumbar interbody fusion; MED, microendoscopic discectomy; PELD, percutaneous endoscopic lumbar discectomy; VAS, visual analogue scale; ODI, Oswestry Disability Index; SF-12, 12-item Short Form Health Survey; PCS, physical component summary; MCS, mental component summary. *Statistically significant differences.
group (16.50 7.31) exhibited a greater improvement in the ODI score than did the patients in the MIS-TLIF group (12.92 3.72, P ¼ 0.030) at 1 month after surgery. In terms of the SF-12 PCS/MCS scores, the patients in MIS-TLIF group (PCS, 5.58 10.13; MCS, 6.30 7.81) exhibited poorer improvement than did those in both the MED (PCS, 12.75 9.52, P ¼ 0.012;
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MCS, 12.39 9.29, P ¼ 0.012) and PELD groups (PCS, 13.39 8.50, P ¼ 0.003; MCS, 11.70 6.99, P ¼ 0.015; Table 2). Perioperative Outcomes and Cost The operation time in the MIS-TLIF group (146.54 38.07 minutes) was significantly longer than those in the MED group
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Table 3. Summary of Perioperative Outcomes, Cost, Complication, and Recurrence MIS-TLIF
MED
PELD
P Value
Operation time, minutes
146.54 38.07
85.25 41.60
75.00 31.56
<0.001* <0.001y <0.001z 0.344x
Blood loss, mL
148.46 74.76
Not measurable
Not measurable
14.96 5.36
8.75 2.22
8.86 3.34
<0.001* <0.001y <0.001z 0.927x
67913.65 14395.18
18005.65 8159.06
15817.25 5055.67
<0.001* <0.001y <0.001z 0.458x
1 (3.85)
2 (10.00)
4 (14.29)
0.422*
0 (0)
3 (15.00)
7 (25.00)
0.026* 0.631x 0.024k
Hospital stay, days
Total cost, RMB
Complications, n (%) Recurrence, n (%)
MIS-TLIF, minimally invasive transforaminal lumbar interbody fusion; MED, microendoscopic discectomy; PELD, percutaneous endoscopic lumbar discectomy; RMB, Yuan Renminbi. *Difference of total rate. yDifference between MIS-TLIF group and MED group. zDifference between MIS-TLIF group and PELD group. xDifference between MED group and PELD group. kDifference between MIS-TLIF group and (MED þ PELD) group.
(85.25 41.60 minutes, P < 0.001) and PELD groups (75.00 31.56 minutes, P < 0.001). In addition, there was no significant difference in the operation time between the MED and PELD groups (P ¼ 0.344). There was no measurable blood loss in either the MED or PELD groups, and the intraoperative blood loss was 148.46 74.76 mL in the MIS-TLIF group. The hospital stay in the MIS-TLIF group (14.96 5.36 days) was significantly longer than those in the MED (8.75 2.22 days, P < 0.001) and PELD groups (8.86 3.34 days, P < 0.001). There was no significant difference in hospital stay between the MED and PELD groups (P ¼ 0.927). The total cost in the MIS-TLIF group (67,913.65 14,395.18 Yuan Renminbi [RMB]) was significantly greater than the costs in the MED (18,005.65 8159.06 RMB, P < 0.001) and PELD groups (15,817.25 5055.67 RMB, P < 0.001). There also was no significant difference in the hospital stay between the MED and PELD groups (P ¼ 0.458; Table 3). Operation Complications and Recurrences Complications occurred in 1 patient (3.85%) in the MIS-TLIF group, 2 patients (10.00%) in the MED group, and 4 patients (14.29%) in the PELD group. One patient in the MIS-TLIF group suffered an incidental durotomy. Two patients in the MED group and 2 patients in the PELD group experienced dysesthesia after surgery. Two patients in the PELD group (one was a 67-year-old man, and the other was a 62-year-old man; the bottle
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containing normal saline was hung 1.2 m greater than the level of patient to provide irrigation pressure) experienced headache intraoperatively, and they both improved at 1 day postoperatively with sufficient bed rest. No significant differences in the complication rates were observed between the 3 groups (P ¼ 0.422). During the follow-up period, no patients in the MIS-TLIF group (0.00%), 3 patients in the MED group (15.00%), and 7 patients in the PELD group (25.00%) suffered from recurrence (information about patients who experienced re-recurrence can be found in Supplementary Table 1). The recurrence rate of the patients in the MIS-TLIF group was significantly lower than those in the MED and PELD groups (P ¼ 0.024; Table 3). DISCUSSION The recurrence rate after PELD has been reported to be 0%e7.4%.1,9,11,12 Revision surgery is necessary for patients who fail to respond to conservative therapy. No study, however, has focused on the selection of the revision surgery method for the recurrence of PELD. It is well known that recurrent herniation is regarded as a major indication for TLIF or repeated discectomy.13,14 Currently, MIS-TLIF and MED/PELD are considered as commendable alternatives to open TLIF and discectomy.15-17 In the present study, we compared the outcomes of these 3 operation methods for PELD recurrence and sought to provide a reference for the selection of revision surgery.
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SURGICAL METHODS FOR PELD RECURRENCE
Comparison of the Clinical Outcomes Generally, all the pain and functional parameters were improved significantly postoperatively compared with the baseline levels before the surgeries in the 3 groups. These favorable outcomes are consistent with the results of previous studies.15-17 In addition, there were no significant differences between the 3 groups for any of the scores over time. The back pain-relief effect in the MIS-TLIF group was worse than that in the nonfusion group (MED/PELD) at 1 month after surgery. This result may be due to the relatively larger injury incurred during interbody fusion compared with discectomy. At the time point of 1 month after surgery, the patients experienced more predominant back pain than leg pain for the fusion versus discectomy procedures. We believe that the leg pain was caused by nerve compression, which can obviously be relieved by either fusion or discectomy. The relatively larger injury to the paravertebral tissue caused by fusion surgery compared with diskectomy, however, may lead to more back pain (vs. discectomy) in the short term after surgery. At the time point of 12 months after surgery, the patients experienced more predominant back pain in the PELD group than in the MIS-TLIF group, and there was no significant difference in the leg pain scores between the 2 groups. We believe these findings can be explained by the greater tendency towards spinal instability and re-recurrence after PELD (re-recurrence rate: 25%) compared with MIS-TLIF (re-recurrence rate: 0%). Given that the follow-up period in this study was relatively short (12 months), back pain may only be the initial symptom, and it will be necessary to follow this patient cohort for a longer period to determine whether the difference in leg pain symptoms will reappear. A reduction of the ODI score of 15 points could reflect clinical improvement.18 The SF-12 PCS/MCS scores were used to assess the health-related quality of life.19 Both the ODI and SF-12 PCS/MCS scores exhibited trends that were similar to that of the VAS scores, indicating that the clinical status and quality of life were highly involved with the pain level.
and the working channel might compress the exiting root intraoperatively; thus, a prolonged operation time would contribute to nerve irritation.23 Therefore, we believe that these complications observed in our study were all associated with difficulties in manipulation. The potential reasons for these difficulties may be as follows: 1) the inherent difficulties of revision surgery, such as scar formation and the distorted anatomical landmarks, make the procedure more technically demanding than the primary surgery; and 2) the learning curves for minimally invasive surgical techniques are steep. Therefore, we believe that revision surgeries for PELD recurrence should be assigned to experienced surgeons for the safety of the patients, and novice surgeons should receive sufficient training. There were no patients in the MIS-TLIF group, 3 patients in the MED group, and 7 patients in the PELD group who suffered from recurrent herniation. The recurrence rate among the patients in the MIS-TLIF group was significantly lower than the rates in the nonfusion groups. The reasons for these findings may be as follows. 1) There were some common risk factors that were predictive of recurrence in both the MED and PELD groups. For example, old age, obesity, and Modic change have been reported to be risk factors for both MED recurrence and PELD recurrence.3,24 The participants who experienced recurrence after revision surgery were either older (60 years old) or obese (body mass index 25), and these patients were at high risk for recurrent herniation after either MED or PELD. The risk factors for recurrence after the primary surgery also might predict recurrence after the secondary surgery. 2) After the primary PELD surgery, the artificial incision in the annulus fibrosus could alter the interlaminar shear stress and make the annulus fibrosus more prone to delamination. Consequently, recurrent herniations tend to form based on the damage to the annulus fibrosus.25 Therefore, MED or PELD may be not able to effectively solve this problem, and thorough interbody fusion (MIS-TLIF) might be a better selection.
Comparison of the Perioperative Outcomes and Cost Consistent with previous studies, the operation times, hospital stays, blood losses, and total costs for the patients in the MED and PELD groups were significantly lower than those of the MIS-TLIF group.15-17 Although the relationships between these parameters and the health of the patients are uncertain, these factors may influence the patients’ mental health to some extent.
Limitations It is necessary to note that the present study has some limitations. 1) It was a retrospective study. 2) The sample size was small (MIS-TLIF, n ¼ 26; MED, n ¼ 20; PELD, n ¼ 28). 3) The follow-up period was short (12 months), and some diseases (such as adjacent segment disease) can only be observed after a longer followup period. A prospective randomized controlled trial with a larger sample size and a longer follow-up period is necessary to provide more helpful information about the assessments of these 3 surgical methods for PELD recurrence.
Comparison of Complications and Recurrences In this study, 1 patient in the MIS-TLIF group experienced an incidental durotomy, which is a common complication of revision spinal surgery.20,21 The occurrence of incidental durotomy is associated with the proficiency of the use of tubular retractors. The limited visual field increases the operational difficulties. In addition, 2 patients in MED group and 2 patients in PELD group experienced postoperative dysaesthesia, and 2 patients in PELD group experienced intraoperative headache. These complications also might be strongly related to the surgeon’s proficiency in the operation. Previous studies have reported that the intracranial pressure increases if the endoscopic operation time is too long,22
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CONCLUSIONS In this study, the outcomes of MIS-TLIF, MED, and PELD as revision surgeries for PELD recurrence were compared. Generally, there were no significant differences in the clinical outcomes over time between these 3 operation methods. MED and PELD were associated with greater pain relief at 1 month after surgery compared with MIS-TLIF, but this effect was neutralized at 3 months postoperatively. MED and PELD
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2017.01.089
ORIGINAL ARTICLE YUAN YAO ET AL.
SURGICAL METHODS FOR PELD RECURRENCE
exhibited advantages in terms of reductions in operation time, blood loss, hospital stay, and total cost compared with MIS-TLIF. However, MED and PELD also were significantly associated with greater recurrence rates compared with MIS-TLIF. Thus, when evaluating a minimally invasive revision surgery for PELD recurrence, the advantages should be
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carefully weighed against the potential disadvantages, and the patients should be informed fully. ACKNOWLEDGMENTS We thank Yangyi Zheng for the collection of data.
10. Yeung AT, Tsou PM. Posterolateral endoscopic excision for lumbar disc herniation: Surgical technique, outcome, and complications in 307 consecutive cases. Spine (Phila Pa 1976). 2002;27: 722-731. 11. Choi KC, Kim JS, Kang BU, Lee CD, Lee SH. Changes in back pain after percutaneous endoscopic lumbar discectomy and annuloplasty for lumbar disc herniation: a prospective study. Pain Med. 2011;12:1615-1621. 12. Jang JS, An SH, Lee SH. Transforaminal percutaneous endoscopic discectomy in the treatment of foraminal and extraforaminal lumbar disc herniations. J Spinal Disord Tech. 2006;19:338-343. 13. El SA, El WM, Morsi AM. Recurrent lumbar disc herniation: a prospective comparative study of three surgical management procedures. Asian J Neurosurg. 2013;8:139-146. 14. 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;31:1473-1476. 15. Ahn SS, Kim SH, Kim DW, Lee BH. Comparison of outcomes of percutaneous endoscopic lumbar discectomy and open lumbar microdiscectomy for young adults: a retrospective matched cohort study. World Neurosurg. 2016;86:250-258. 16. Parker SL, Mendenhall SK, Shau DN, Zuckerman SL, Godil SS, Cheng JS, et al. Minimally invasive versus open transforaminal lumbar interbody fusion for degenerative spondylolisthesis: comparative effectiveness and cost-utility analysis. World Neurosurg. 2014;82:230-238. 17. Wu X, Zhuang S, Mao Z, Chen H. Microendoscopic discectomy for lumbar disc herniation: surgical technique and outcome in 873 consecutive cases. Spine (Phila Pa 1976). 2006;31: 2689-2694. 18. Deutsch H. The predictive value of the baseline Oswestry Disability Index in lumbar disc arthroplasty. Neurosurg Focus. 2010;28:E7.
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19. Lam CL, Tse EY, Gandek B. Is the standard SF-12 health survey valid and equivalent for a Chinese population? Qual Life Res. 2005;14:539-547. 20. Cammisa FJ, Girardi FP, Sangani PK, Parvataneni HK, Cadag S, Sandhu HS. Incidental durotomy in spine surgery. Spine (Phila Pa 1976). 2000;25:2663-2667. 21. Wang JC, Bohlman HH, Riew KD. Dural tears secondary to operations on the lumbar spine. Management and results after a two-yearminimum follow-up of eighty-eight patients. J Bone Joint Surg Am. 1998;80:1728-1732. 22. Sairyo K, Matsuura T, Higashino K, Sakai T, Takata Y, Goda Y, et al. Surgery related complications in percutaneous endoscopic lumbar discectomy under local anesthesia. J Med Invest. 2014; 61:264-269. 23. Choi I, Ahn JO, So WS, Lee SJ, Choi IJ, Kim H. Exiting root injury in transforaminal endoscopic discectomy: preoperative image considerations for safety. Eur Spine J. 2013;22:2481-2487. 24. Yao Y, Liu H, Zhang H, Wang H, Zhang Z, Zheng Y, et al. Risk factors for the recurrent herniation after microendoscopic discectomy. World Neurosurg. 2016;95:451-455. 25. Iatridis JC, Ap GI. Mechanisms for mechanical damage in the intervertebral disc annulus fibrosus. J Biomech. 2004;37:1165-1175.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 29 October 2016; accepted 23 January 2017 Citation: World Neurosurg. (2017) 100:641-647. http://dx.doi.org/10.1016/j.wneu.2017.01.089 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2017 Elsevier Inc. All rights reserved.
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ORIGINAL ARTICLE YUAN YAO ET AL.
SURGICAL METHODS FOR PELD RECURRENCE
SUPPLEMENTARY DATA
Supplementary Table 1. Information of Patients with Re-recurrence Number of Patients
Revision Surgery Methods
1
MED
Male
76
27.83
2
MED
Female
74
26.56
3
MED
Male
56
31.60
4
PELD
Female
68
22.40
5
PELD
Female
45
28.03
6
PELD
Female
48
29.06
7
PELD
Female
41
26.80
8
PELD
Male
58
27.62
9
PELD
Male
56
31.60
10
PELD
Female
65
34.13
Sex
Age, years
BMI
BMI, body mass index; MED, microendoscopic discectomy; PELD, percutaneous endoscopic lumbar discectomy.
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