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Transforaminal percutaneous endoscopic discectomy for lumbar disc herniation in athletes under the local anesthesia
Journal of Orthopaedic Science 24 (2019) 1015e1019
Contents lists available at ScienceDirect
Journal of Orthopaedic Science journal homepage: http://www.elsevier.com/locate/jos
Original Article
Transforaminal percutaneous endoscopic discectomy for lumbar disc herniation in athletes under the local anesthesia Toshio Nakamae a, Yoshinori Fujimoto b, Kiyotaka Yamada b, Kazuyoshi Nakanishi a, *, Naosuke Kamei a, Ken Yoshizaki c, Nobuo Adachi a a b c
Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan Department of Orthopaedic Surgery, JA Hiroshima General Hospital, Hiroshima, Japan Sanfrecce Hiroshima FC, Hiroshima, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 1 June 2019 Received in revised form 7 July 2019 Accepted 15 July 2019 Available online 23 August 2019
Background: Percutaneous endoscopic discectomy (PED) has been reported to be less invasive and effective procedure for lumbar disc herniation (LDH). Damage to the back muscle is considered minimal, which is particularly important for athletes. However, the results of PED for LDH in athletes have not been reported well. The purpose of this study was to evaluate the clinical outcomes of PED for LDH in athletes. Methods: We retrospectively analyzed 21 athlete patients with LDH who had undergone PED. All patients received athletic rehabilitation immediately after surgery. The clinical outcomes were evaluated from the visual analogue scale (VAS) for leg pain and low back pain (LBP), the Oswestry Disability Index (ODI), complications and periods of return to sport. Results: There were 18 men and 3 women, and the mean age at the time of surgery was 22.9 years (range: 15e43 years). The mean VAS scores for leg pain before and after surgery were 64.3 ± 2.7 mm and 12.4 ± 1.4 mm, respectively. The mean VAS scores for LBP before and after surgery were 62.1 ± 2.2 mm and 10.5 ± 1.1 mm, respectively. The mean ODI scores before and after surgery were 31.3 ± 14.0% and 14.6 ± 7.1%, respectively. The VAS for leg pain, as well as the LBP and ODI, significantly improved after surgery. There were no complications related to the surgery. Ninety-five percent (20/21) returned to play sports at the same performance level as before the procedure by an average of 9.2 weeks after PED. Conclusions: PED is a minimally invasive and effective procedure for patients with LDH, especially in athletes. Not only the patients' leg pain but also their discogenic LBP improved. PED has the benefits of preservation of normal posterior structures and a faster return to sports. © 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
1. Introduction Lumbar disc herniation (LDH) is a common disease for young patients and is a major cause of low back pain (LBP) and leg pain. While benign natural history has been proposed and conservative treatment has been usually chosen for LDH patients, some LDH patients whose symptoms endure after conservative treatment may require surgical intervention [1,2]. Although open lumbar discectomy is a gold standard surgical method for LDH, surgery-
* Corresponding author. Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan. Fax: þ81 82 257 5234. E-mail address: [email protected] (K. Nakanishi).
induced tissue injury such as muscle injury or denervation may become a source of postsurgical pain [3,4]. It is especially important for athletes to return to sporting activity as quickly as possible, because undue delay in returning to training may result in poor performance and relegation from the regular position. For this quick return to be possible, athletes need to undergo a less invasive surgical procedure to preserve muscle, as well as to prevent bone damage [5,6]. Percutaneous endoscopic discectomy (PED) is a relatively novel procedure for LDH. In many cases, this procedure is performed through the transforaminal approach without bone resection, thus preserving spinal stability. PED has been reported as a minimally invasive spinal surgery procedure and has been shown to have advantages such as reduced risk of surgery-induced tissue injury, faster rehabilitation, preservation of mobility of the operation
https://doi.org/10.1016/j.jos.2019.07.019 0949-2658/© 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
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T. Nakamae et al. / Journal of Orthopaedic Science 24 (2019) 1015e1019
segments compared with open discectomy techniques [3,7e11]. Hijikata was first to introduce the percutaneous transforaminal nucleotomy without an endoscope [12]. A subsequent study reported the usefulness of PED for some kinds of LDH [3,4,13e15]. However there have been few reports about PED for athletes [16]. The purpose of this study was to evaluate the clinical outcomes of PED for LDH in athletes. 2. Materials and methods 2.1. Patient selection We retrospectively analyzed 21 patients with LDH from 2012 to 2017. These patients were all competitive athletes who underwent PED. Athletic events are 7 football, 4 baseball, 2 volleyball, tennis and track and field, 1 basketball, bicycle race, boxing and pingpong. The level of sporting activity included professional, semiprofessional, club team, high school and collegiate. PED was indicated when the patient had radicular leg pain due to lumbar nerve root compression, had failed conservative therapy and had the diagnosis of lumbar disc herniation from magnetic resonance imaging (MRI). Exclusion criteria was disc herniation sequestrated cranially on the upper or lower edge of the cranial pedicle or caudally over the caudal pedicle, foraminal stenosis, motor weakness of lower extremity and high iliac crest. Because PED was performed with local anesthesia, patients who could not be put into a prone position due to pain, were also excluded. This study was approved by our institutional review board and all patients provided written informed consent to undergo PED prior to participation in this study. 2.2. PED procedure PED was performed by experienced spinal surgeons. Under local anesthesia in a prone position with on a radiolucent four-poster spinal frame, an 8 mm skin incision was made about 10e12 cm lateral to the midline. An 18-gauge spinal needle was introduced under fluoroscopic imaging. Infiltration with 1% mepivacaine into the surface of the annulus fibrosus was done through the spinal needle to reduce pain. Following insertion of a spinal needle into the disc, an intraoperative discogram with a mixture of indigo carmine and contrast medium was made. We confirmed leakage of the contrast medium through the tear in the anulus and epidural space, indicating that the herniated fragment of the nucleus pulposus should be stained blue, helping to identify the herniated fragment. A guide wire was then inserted through the spinal needle and the needle was removed. A cannulated obturator was slid over the guidewire and introduced into the foramen and into the disc. An endoscope was inserted into the disc and discectomy was performed via the transforaminal approach. Then, according to the inside-out and hand-down technique, the cannula was moved toward the epidural space, the herniated fragment was removed. 2.3. Clinical assessments The clinical outcomes were evaluated using the visual analogue scale (VAS; 0e100 mm) for leg pain and LBP. Physical disability was measured using the Oswestry Disability Index (ODI) on a scale of 0e100%, with higher scores indicating greater disability. Complications related to the surgery, operating time and suffering periods of LBP were also evaluated. Orthopedic surgeons not involved in the treatment performed the follow-up and clinical examinations to assess the patients' functional status. The VAS and ODI questionnaire were self-administered and collected by a medical secretary to avoid interviewer bias.
2.4. Athletic rehabilitation The patients received athletic rehabilitation with a physical trainer or physical therapist immediately after the surgery. Patients could walk in the hospital on the day of the surgery and could do hip-stretching exercises. One week after surgery, corestrengthening and stretching exercises commenced. This core stabilization program consisted of coordination of the trunk muscles, establishing a neutral position and gaining isometric control of trunk mobilization. Three weeks after surgery, patients started jogging and balance training. The next week, patients started interval training and agility training. Six weeks after surgery, they could return to sports activity depending on the extent of their recovery. The patients also received mobilization and core muscle strength training after their return to sports activity [Table 1]. 2.5. Statistical analysis To analyze the clinical data of the patients, we compared the clinical parameters before and after surgery. Clinical characteristics were analyzed using the Wilcoxon signed-ranks test. Statistical significance was defined as the level of P < 0.05 for a 2-sided hypothesis. Mean values are presented ± standard deviation. 3. Results 3.1. Clinical assessments There were 18 men and 3 women, and the mean age at the time of surgery was 22.9 years (range: 15e43 years) [Table 2]. The mean duration of the symptoms was 5.2 months (range: 2.5e12 months). The spinal level of PED was L4-5 in all patients. Before the surgery, all patients showed signal change of intervertebral disc on MRI using Pfirrmann classification (Grade II:15 patients, Grade III: 6 patients). As for the type of the herniation, 17 showed subligamentous extrusion type and 4 showed transligamentous extrusion type. There were no Modic change on the vertebral endplate on MRI except for 1 patient with Modic type 1 change. There were no patients with intervertebral instability. All patients showed hamstring tightness before surgery. The mean follow-up periods after surgery was 28.1 months (range: 12e84 months). The mean VAS scores for leg pain before and after surgery were 64.3 ± 2.7 mm and 12.4 ± 1.4 mm, respectively. The mean VAS scores for LBP before and after surgery were 62.1 ± 2.2 mm and 10.5 ± 1.1 mm, respectively. The mean ODI scores before and after surgery were 31.3 ± 14.0% and 14.6 ± 7.1%, respectively. The VAS for leg pain and LBP and ODI significantly improved after surgery [Table 3]. The mean operating time was 82 min (range: 49e129 min). There were no complications related to the surgery such as root injury, dural tear and infection. All patients except one showed improvement of symptoms immediately after surgery. One patient could not complete the PED procedure because of the existence of detached ring apophysis. This patient underwent additional microsurgical lumbar discectomy. One patient (5%) suffered from recurrence of LDH 10 months after PED and was treated conservatively. 3.2. Athletic rehabilitation All patients received sports rehabilitation with athletic trainers or physical therapists after the surgery. Patients were then allowed to return to sports activity 6 weeks after surgery, dependent on their rehabilitation. Ninety-five percent (20/21) returned to the same level of sporting activity as before the procedure, at an average of 9.2 weeks (range: 6e28 weeks) after PED.
T. Nakamae et al. / Journal of Orthopaedic Science 24 (2019) 1015e1019 Table 1 Athletic rehabilitation programs after percutaneous endoscopic discectomy. contents 1 week after surgery
3 weeks after surgery 4 weeks after surgery 6 weeks after surgery
exercise to strengthen the core of the body and stretch of the body jogging and balance training interval and agility training allowed to return to the sports activity dependent on the performance
Table 2 Demographics of the 21 patients. Data Sex Male Female Age Height Weight BMI Athletic events Football Baseball Volleyball, tennis, track and field Basketball, bicycle race, boxing, ping-pong
18 patients 3 patients 22.9 years (15e43 years) 173 cm (149e195 cm) 66.5 kg (46) 22.1 7 patients 4 patients 2 patients
1 patient
3.3. Case presentation A 23-year-old collegiate regular football player presented with LBP and radicular pain in his right buttock. MRI revealed a herniated disc at right L4-5 [Fig. 1a, b]. He underwent PED at L4-5 and received athletic rehabilitation after surgery. Immediately after surgery, his LBP and radicular pain in the right buttock improved, and MRI revealed resection of the herniated disc [Fig. 1c, d]. He was able to return to football 10 weeks after surgery at the same performance as before the PED. 4. Discussion PED is a minimally invasive and effective procedure for patients with LDH, especially in athletes. The patients improved not only in terms of their leg pain but also regarding their discogenic LBP. PED has the benefits of surgery under local anesthesia, preservation of normal posterior structures, less postoperative pain and faster return to sports. 4.1. Effectiveness and invasiveness of PED PED has been reported as a minimally invasive procedure for LDH and has advantages such as the preservation of the normal posterior and paraspinal structures such as ligaments, muscle,
Table 3 Clinical outcomes of visual analogue scale for leg pain and low back pain and Oswestry Disability Index (PED: percutaneous endoscopic discectomy, VAS: visual analogue scale, LBP: low back pain, ODI: Oswestry Disability Index).
VAS for leg pain VAS for LBP ODI
Baseline (mean ± SD)
After PED (mean ± SD)
P value*
64.3 ± 2.7 mm 62.1 ± 2.2 mm 31.3 ± 14.0%
12.4 ± 1.4 mm 10.5 ± 1.1 mm 14.6 ± 7.1%
P < 0.05 P < 0.05 P < 0.05
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lamina and facet joints, less postoperative pain and faster rehabilitation [7e11]. Ruetten et al. performed a prospective randomized controlled study of full-endoscopic interlaminar and transforaminal lumbar discectomy versus the conventional microsurgical technique for lumbar disc herniation [3]. They concluded that these two surgical techniques exhibit similar clinical therapeutic effects and that the endoscopic procedure resulted in a smaller epidural scar and smaller wound. Choi et al. reported PED can be an effective treatment for lumbar disc herniation, and it is associated with potential advantages, including a rapid recovery, improvements in back pain and disc height preservation compared with open lumbar microdiscectomy [11]. Yamashita et al. reported that repeat PED surgery for recurrence of LDH after PED is an effective method because of the minimal adhesion around the nerve [17]. PED is an atraumatic procedure for LDH and might be useful for the repeat recurrence LDH. 4.2. Low back pain and PED Patients with LDH often suffered from not only sciatic pain but also LBP. It has been reported that PED is used for chronic discogenic LBP [16,18,19]. The PED procedure is used in these studies, with the tear of the posterior annulus fibrosus modulated by a bipolar radiofrequency coagulator, known as the thermal annuloplasty technique. PED and thermal annuloplasty was shown to be effective for discogenic LBP. In our study, not only leg pain but also their discogenic LBP improved after PED without thermal annuloplasty. The precise pathophysiology is not clear from our study, but a decrease in the intradiscal pressure might be one of the causes of LBP reduction. Kambin et al. reported that the rapid decline of intradiscal pressure after percutaneous transforaminal nucleotomy appears to show good results for LDH patients [20]. Especially in young LDH patients such as athletes, intradiscal pressure tends to be high, and reduction of intradiscal pressure with percutaneous discectomy might be useful for young discogenic LBP patients [20e23]. Moreover, annular tear and leakage of the nucleus pulposus to the surface of the anulus fibrosus might induce an inflammatory reaction and LBP [24,25]. Leakage of the nucleus pulposus induces an immunoreaction and recruitment of the inflammatory cytokine and mediators such as tumor necrotic factor and interleukin. PED might be useful for discogenic LBP in young patients through reduction of the intradiscal pressure and extrusion of the nucleus pulposus from the surface of the anulus fibrosus, thus reducing inflammation. 4.3. Return to play To athletes, LDH leads to poor performance and inability to play sports because of LBP and leg pain. Athletes hope to return to sporting activity as quickly as possible, because a delay may result in loss of performance condition and relegation from the regular status or team position. Some studies reported that patients with LDH in the general population improved both through surgery and usual conservative care in the long term [26,27]. However, athletes need to return to play their sports quickly and sometimes they need to undergo surgery, so therefore a less invasive surgical procedure is necessary, in order to preserve muscle and prevent bone damage such as PED [5,6]. However, reports on the effect of PED on LDH in athletes are rare. Sairyo et al. reported the efficacy of PED with thermal annuloplasty in 4 professional athletes [16]. They concluded that PED is a minimally invasive procedure especially for athletes. Abe et al. reported on foraminoplastic transforaminal PED in a rugby player, who returned to rugby practice 8 weeks after surgery and was able to play competition rugby 4 months after surgery [28]. In our study, all patients received athletic
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Fig. 1. Magnetic resonance image showed lumbar disc herniation at L4-5 before surgery (a: T2-weighted sagittal image, b: T2-weighted axial image). After surgery, lumbar disc herniation was removed (c: T2-weighted sagittal image, d: T2-weighted axial image).
rehabilitation after surgery and they could return to sporting activity 6 weeks after surgery depending on the extent of their recovery. In actual fact, 93% (20/21) returned to the same level of sporting activity as before the procedure, at an average of 9.2 weeks after PED. As for the return to play after lumbar surgery, a literature review showed 83.5% of the elite athletes who underwent microscopic lumbar discectomy for LDH returned to play [6]. Watkins et al. reported the average time from microscopic lumbar discectomy to return to play was 5.2 months (range: 1e15 months) for the entire group [5]. Yoshimoto et al. reported the mean period until complete return to competition after microscopic lumbar discectomy was 10.8 weeks (range: 5e16 weeks) [29]. However, the timing of the return to play after lumbar surgery is controversial and no definitive accurate timing advice for return to play after PED is given. We allowed patients to return to sporting activity 6 weeks after surgery depending on the extent of their recovery. All patients received sports rehabilitation with athletic trainers or physical therapists immediately after surgery. One week after PED, corestrengthening exercises commenced. This core stabilization program consists of coordination of the torso muscles, establishing a neutral position, and gaining isometric control of the torso's mobilization. Sports rehabilitation is an essential program to facilitate the return to previous sports activity. In conclusion, PED is a minimally invasive and effective surgical procedure for patients with LDH especially for athletes. The patients improved not only in terms of leg pain but also regarding their discogenic LBP. PED has the benefits of surgery under local anesthesia, preservation of normal posterior structures, less postoperative pain and a faster return to sports. 5. Conclusions PED is a minimally invasive and effective procedure for patients with LDH, especially in athletes. Not only the patients' leg pain but also their discogenic LBP improved. PED could offer a high possibility of an early return to the same level of sports activity. Conflict of interest The authors confirm that this article content has no conflict of interest. No funds were received in support of this work. References [1] Weber H. Lumbar disc herniation: a controlled, prospective study with ten years of observation. Spine 1983 Mar;8(2):131e40.
[2] Jensen TS, Albert HB, Soerensen JS, Manniche C, Leboeuf-Yde C. Natural course of disc morphology in patients with sciatica: an MRI study using a standardized qualitative classification system. Spine 2006 Jun 15;31(14):1605e12. [3] Ruetten S, Komp M, Merk H, Godolias G. Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study. Spine 2008 Apr;33(9): 931e9. [4] Hermantin FU, Peters T, Quartararo L, Kambin P. A prospective, randomized study comparing the results of open discectomy with those of video-assisted arthroscopic microdiscectomy. J Bone Joint Surg Am 1999 Jul;81(7):958e65. [5] Watkins 4th RG, Williams LA, Watkins 3rd RG. Microscopic lumbar discectomy results for 60 cases in professional and Olympic athletes. Spine J 2003 Mar-Apr;3(2):100e5. [6] Tencone F, Minetto MA, Tomaello L, Giannini A, Roi GS. Return to competition after surgery for herniated lumbar disc in professional football players. Clin J Sport Med 2018 Aug 28 [Epub ahead of print]. [7] Mayer HM, Brock M. Percutaneous endoscopic discectomy: surgical technique and preliminary results compared to microsurgical discectomy. J Neurosurg 1993 Feb;78(2):216e25. [8] Kambin P, Casey K, O'Brien E, Zhou L. Transforaminal arthroscopic decompression of lateral recess stenosis. J Neurosurg 1996 Mar;84(3):462e7. [9] Yeung AT, Tsou PM. Posterolateral endoscopic excision for lumbar disc herniation: surgical technique, outcome, and complications in 307 consecutive cases. Spine 2002 Apr 1;27(7):722e31. [10] 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 2004 Aug 15;29(16): 326e32. [11] Choi KC, Kim JS, Park CK. Percutaneous endoscopic lumbar discectomy as an alternative to open lumbar microdiscectomy for large lumbar disc herniation. Pain Physician 2016 Feb;19(2):E291e300. [12] Hijikata S. Percutaneous nucleotomy. A new concept technique and 12 years' experience. Clin Orthop Relat Res 1989 Jan;238:9e23. [13] Schreiber A, Leu H. Percutaneous nucleotomy: technique with discoscopy. Orthopedics 1991 Apr;14(4):439e44. [14] Dezawa A, Sairyo K. New minimally invasive discectomy technique through the interlaminar space using a percutaneous endoscope. Asian J Endosc Surg 2011 May;4(2):94e8. [15] Dezawa A, Mikami H, Sairyo K. Percutaneous endoscopic translaminar approach for herniated nucleus pulposus in the hidden zone of the lumbar spine. Asian J Endosc Surg 2012 Nov;5(4):200e3. [16] Sairyo K, Kitagawa Y, Dezawa A. Percutaneous endoscopic discectomy and thermal annuloplasty for professional athletes. Asian J Endosc Surg 2013 Nov;6(4):292e7. [17] Yamashita K, Higashino K, Sakai T, Takata Y, Abe M, Morimoto M, Nagamachi A, Sairyo K. Revision percutaneous endoscopic lumbar discectomy under the local anesthesia for the recurrent lumbar herniated nucleus pulposus in a high class athlete: a case report. J Med Investig 2016;63(1e2): 135e9. [18] Tsou PM, Alan Yeung C, Yeung AT. Posterolateral transforaminal selective endoscopic discectomy and thermal annuloplasty for chronic lumbar discogenic pain: a minimal access visualized intradiscal surgical procedure. Spine J 2004 Sep-Oct;4(5):564e73. [19] Ahn Y, Lee SH. Outcome predictors of percutaneous endoscopic lumbar discectomy and thermal annuloplasty for discogenic low back pain. Acta Neurochir 2010 Oct;152(10):1695e702. [20] Kambin P, Brager MD. Percutaneous posterolateral discectomy. Anatomy and mechanism. Clin Orthop Relat Res 1987 Oct;223:145e54. [21] Tsuji H, Yoshioka T, Sainoh H. Developmental balloon disc of the lumbar spine in healthy subjects. Spine 1985 Dec;10(10):907e11.
T. Nakamae et al. / Journal of Orthopaedic Science 24 (2019) 1015e1019 [22] Castagnera L, Grenier N, Lavignolle B, Greselle JF, Senegas J, Caille JM. Study of correlation between intradiscal pressure and magnetic resonance imaging data in evaluation of disc degeneration. Therapeutic issue with percutaneous nucleotomy. Spine 1991 Mar;16(3):348e52. [23] Castagnera L, Lavignolle B. Intrinsic disc pressure as a measure of integrity of the lumbar spine. Spine 1989 Jul;14(7):777. [24] Olmarker K. Puncture of a lumbar intervertebral disc induces changes in spontaneous pain behavior: an experimental study in rats. Spine 2008 Apr;33(8):850e5. [25] Nakamae T, Ochi M, Olmarker K. Pharmacological inhibition of tumor necrosis factor may reduce pain behavior changes induced by experimental disc puncture in the rat: an experimental study in rats. Spine 2011 Feb 15;36(4): 232e6. [26] Weinstein JN, Lurie JD, Tosteson TD, Skinner JS, Hanscom B, Tosteson AN, Herkowitz H, Fischgrund J, Cammisa FP, Albert T, Deyo RA. Surgical vs
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nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 2006 Nov;296(20): 2451e9. [27] Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Hanscom B, Skinner JS, Abdu WA, Hilibrand AS, Boden SD, Deyo RA. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA 2006 Nov 22;296(20):2441e50. [28] Abe M, Takata Y, Higashino K, Sakai T, Matsuura T, Suzue N, Hamada D, Goto T, Nishisho T, Goda Y, Tsutsui T, Tonogai I, Miyagi R, Morimoto M, Mineta K, Kimura T, Nitta A, Hama S, Higuchi T, C Jha S, Takahashi R, Fukuta S, Sairyo K. Foraminoplastic transforaminal percutaneous endoscopic discectomy at the lumbosacral junction under local anesthesia in an elite rugby player. J Med Investig 2015;62(3e4):238e41. [29] Yoshimoto M, Takebayashi T, Ida K, Tanimoto K, Yamashita T. Microendoscopic discectomy in athletes. J Orthop Sci 2013 Nov;18(6):902e8.
Contents lists available at ScienceDirect
Journal of Orthopaedic Science journal homepage: http://www.elsevier.com/locate/jos
Original Article
Transforaminal percutaneous endoscopic discectomy for lumbar disc herniation in athletes under the local anesthesia Toshio Nakamae a, Yoshinori Fujimoto b, Kiyotaka Yamada b, Kazuyoshi Nakanishi a, *, Naosuke Kamei a, Ken Yoshizaki c, Nobuo Adachi a a b c
Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan Department of Orthopaedic Surgery, JA Hiroshima General Hospital, Hiroshima, Japan Sanfrecce Hiroshima FC, Hiroshima, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 1 June 2019 Received in revised form 7 July 2019 Accepted 15 July 2019 Available online 23 August 2019
Background: Percutaneous endoscopic discectomy (PED) has been reported to be less invasive and effective procedure for lumbar disc herniation (LDH). Damage to the back muscle is considered minimal, which is particularly important for athletes. However, the results of PED for LDH in athletes have not been reported well. The purpose of this study was to evaluate the clinical outcomes of PED for LDH in athletes. Methods: We retrospectively analyzed 21 athlete patients with LDH who had undergone PED. All patients received athletic rehabilitation immediately after surgery. The clinical outcomes were evaluated from the visual analogue scale (VAS) for leg pain and low back pain (LBP), the Oswestry Disability Index (ODI), complications and periods of return to sport. Results: There were 18 men and 3 women, and the mean age at the time of surgery was 22.9 years (range: 15e43 years). The mean VAS scores for leg pain before and after surgery were 64.3 ± 2.7 mm and 12.4 ± 1.4 mm, respectively. The mean VAS scores for LBP before and after surgery were 62.1 ± 2.2 mm and 10.5 ± 1.1 mm, respectively. The mean ODI scores before and after surgery were 31.3 ± 14.0% and 14.6 ± 7.1%, respectively. The VAS for leg pain, as well as the LBP and ODI, significantly improved after surgery. There were no complications related to the surgery. Ninety-five percent (20/21) returned to play sports at the same performance level as before the procedure by an average of 9.2 weeks after PED. Conclusions: PED is a minimally invasive and effective procedure for patients with LDH, especially in athletes. Not only the patients' leg pain but also their discogenic LBP improved. PED has the benefits of preservation of normal posterior structures and a faster return to sports. © 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
1. Introduction Lumbar disc herniation (LDH) is a common disease for young patients and is a major cause of low back pain (LBP) and leg pain. While benign natural history has been proposed and conservative treatment has been usually chosen for LDH patients, some LDH patients whose symptoms endure after conservative treatment may require surgical intervention [1,2]. Although open lumbar discectomy is a gold standard surgical method for LDH, surgery-
* Corresponding author. Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan. Fax: þ81 82 257 5234. E-mail address: [email protected] (K. Nakanishi).
induced tissue injury such as muscle injury or denervation may become a source of postsurgical pain [3,4]. It is especially important for athletes to return to sporting activity as quickly as possible, because undue delay in returning to training may result in poor performance and relegation from the regular position. For this quick return to be possible, athletes need to undergo a less invasive surgical procedure to preserve muscle, as well as to prevent bone damage [5,6]. Percutaneous endoscopic discectomy (PED) is a relatively novel procedure for LDH. In many cases, this procedure is performed through the transforaminal approach without bone resection, thus preserving spinal stability. PED has been reported as a minimally invasive spinal surgery procedure and has been shown to have advantages such as reduced risk of surgery-induced tissue injury, faster rehabilitation, preservation of mobility of the operation
https://doi.org/10.1016/j.jos.2019.07.019 0949-2658/© 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
1016
T. Nakamae et al. / Journal of Orthopaedic Science 24 (2019) 1015e1019
segments compared with open discectomy techniques [3,7e11]. Hijikata was first to introduce the percutaneous transforaminal nucleotomy without an endoscope [12]. A subsequent study reported the usefulness of PED for some kinds of LDH [3,4,13e15]. However there have been few reports about PED for athletes [16]. The purpose of this study was to evaluate the clinical outcomes of PED for LDH in athletes. 2. Materials and methods 2.1. Patient selection We retrospectively analyzed 21 patients with LDH from 2012 to 2017. These patients were all competitive athletes who underwent PED. Athletic events are 7 football, 4 baseball, 2 volleyball, tennis and track and field, 1 basketball, bicycle race, boxing and pingpong. The level of sporting activity included professional, semiprofessional, club team, high school and collegiate. PED was indicated when the patient had radicular leg pain due to lumbar nerve root compression, had failed conservative therapy and had the diagnosis of lumbar disc herniation from magnetic resonance imaging (MRI). Exclusion criteria was disc herniation sequestrated cranially on the upper or lower edge of the cranial pedicle or caudally over the caudal pedicle, foraminal stenosis, motor weakness of lower extremity and high iliac crest. Because PED was performed with local anesthesia, patients who could not be put into a prone position due to pain, were also excluded. This study was approved by our institutional review board and all patients provided written informed consent to undergo PED prior to participation in this study. 2.2. PED procedure PED was performed by experienced spinal surgeons. Under local anesthesia in a prone position with on a radiolucent four-poster spinal frame, an 8 mm skin incision was made about 10e12 cm lateral to the midline. An 18-gauge spinal needle was introduced under fluoroscopic imaging. Infiltration with 1% mepivacaine into the surface of the annulus fibrosus was done through the spinal needle to reduce pain. Following insertion of a spinal needle into the disc, an intraoperative discogram with a mixture of indigo carmine and contrast medium was made. We confirmed leakage of the contrast medium through the tear in the anulus and epidural space, indicating that the herniated fragment of the nucleus pulposus should be stained blue, helping to identify the herniated fragment. A guide wire was then inserted through the spinal needle and the needle was removed. A cannulated obturator was slid over the guidewire and introduced into the foramen and into the disc. An endoscope was inserted into the disc and discectomy was performed via the transforaminal approach. Then, according to the inside-out and hand-down technique, the cannula was moved toward the epidural space, the herniated fragment was removed. 2.3. Clinical assessments The clinical outcomes were evaluated using the visual analogue scale (VAS; 0e100 mm) for leg pain and LBP. Physical disability was measured using the Oswestry Disability Index (ODI) on a scale of 0e100%, with higher scores indicating greater disability. Complications related to the surgery, operating time and suffering periods of LBP were also evaluated. Orthopedic surgeons not involved in the treatment performed the follow-up and clinical examinations to assess the patients' functional status. The VAS and ODI questionnaire were self-administered and collected by a medical secretary to avoid interviewer bias.
2.4. Athletic rehabilitation The patients received athletic rehabilitation with a physical trainer or physical therapist immediately after the surgery. Patients could walk in the hospital on the day of the surgery and could do hip-stretching exercises. One week after surgery, corestrengthening and stretching exercises commenced. This core stabilization program consisted of coordination of the trunk muscles, establishing a neutral position and gaining isometric control of trunk mobilization. Three weeks after surgery, patients started jogging and balance training. The next week, patients started interval training and agility training. Six weeks after surgery, they could return to sports activity depending on the extent of their recovery. The patients also received mobilization and core muscle strength training after their return to sports activity [Table 1]. 2.5. Statistical analysis To analyze the clinical data of the patients, we compared the clinical parameters before and after surgery. Clinical characteristics were analyzed using the Wilcoxon signed-ranks test. Statistical significance was defined as the level of P < 0.05 for a 2-sided hypothesis. Mean values are presented ± standard deviation. 3. Results 3.1. Clinical assessments There were 18 men and 3 women, and the mean age at the time of surgery was 22.9 years (range: 15e43 years) [Table 2]. The mean duration of the symptoms was 5.2 months (range: 2.5e12 months). The spinal level of PED was L4-5 in all patients. Before the surgery, all patients showed signal change of intervertebral disc on MRI using Pfirrmann classification (Grade II:15 patients, Grade III: 6 patients). As for the type of the herniation, 17 showed subligamentous extrusion type and 4 showed transligamentous extrusion type. There were no Modic change on the vertebral endplate on MRI except for 1 patient with Modic type 1 change. There were no patients with intervertebral instability. All patients showed hamstring tightness before surgery. The mean follow-up periods after surgery was 28.1 months (range: 12e84 months). The mean VAS scores for leg pain before and after surgery were 64.3 ± 2.7 mm and 12.4 ± 1.4 mm, respectively. The mean VAS scores for LBP before and after surgery were 62.1 ± 2.2 mm and 10.5 ± 1.1 mm, respectively. The mean ODI scores before and after surgery were 31.3 ± 14.0% and 14.6 ± 7.1%, respectively. The VAS for leg pain and LBP and ODI significantly improved after surgery [Table 3]. The mean operating time was 82 min (range: 49e129 min). There were no complications related to the surgery such as root injury, dural tear and infection. All patients except one showed improvement of symptoms immediately after surgery. One patient could not complete the PED procedure because of the existence of detached ring apophysis. This patient underwent additional microsurgical lumbar discectomy. One patient (5%) suffered from recurrence of LDH 10 months after PED and was treated conservatively. 3.2. Athletic rehabilitation All patients received sports rehabilitation with athletic trainers or physical therapists after the surgery. Patients were then allowed to return to sports activity 6 weeks after surgery, dependent on their rehabilitation. Ninety-five percent (20/21) returned to the same level of sporting activity as before the procedure, at an average of 9.2 weeks (range: 6e28 weeks) after PED.
T. Nakamae et al. / Journal of Orthopaedic Science 24 (2019) 1015e1019 Table 1 Athletic rehabilitation programs after percutaneous endoscopic discectomy. contents 1 week after surgery
3 weeks after surgery 4 weeks after surgery 6 weeks after surgery
exercise to strengthen the core of the body and stretch of the body jogging and balance training interval and agility training allowed to return to the sports activity dependent on the performance
Table 2 Demographics of the 21 patients. Data Sex Male Female Age Height Weight BMI Athletic events Football Baseball Volleyball, tennis, track and field Basketball, bicycle race, boxing, ping-pong
18 patients 3 patients 22.9 years (15e43 years) 173 cm (149e195 cm) 66.5 kg (46) 22.1 7 patients 4 patients 2 patients
1 patient
3.3. Case presentation A 23-year-old collegiate regular football player presented with LBP and radicular pain in his right buttock. MRI revealed a herniated disc at right L4-5 [Fig. 1a, b]. He underwent PED at L4-5 and received athletic rehabilitation after surgery. Immediately after surgery, his LBP and radicular pain in the right buttock improved, and MRI revealed resection of the herniated disc [Fig. 1c, d]. He was able to return to football 10 weeks after surgery at the same performance as before the PED. 4. Discussion PED is a minimally invasive and effective procedure for patients with LDH, especially in athletes. The patients improved not only in terms of their leg pain but also regarding their discogenic LBP. PED has the benefits of surgery under local anesthesia, preservation of normal posterior structures, less postoperative pain and faster return to sports. 4.1. Effectiveness and invasiveness of PED PED has been reported as a minimally invasive procedure for LDH and has advantages such as the preservation of the normal posterior and paraspinal structures such as ligaments, muscle,
Table 3 Clinical outcomes of visual analogue scale for leg pain and low back pain and Oswestry Disability Index (PED: percutaneous endoscopic discectomy, VAS: visual analogue scale, LBP: low back pain, ODI: Oswestry Disability Index).
VAS for leg pain VAS for LBP ODI
Baseline (mean ± SD)
After PED (mean ± SD)
P value*
64.3 ± 2.7 mm 62.1 ± 2.2 mm 31.3 ± 14.0%
12.4 ± 1.4 mm 10.5 ± 1.1 mm 14.6 ± 7.1%
P < 0.05 P < 0.05 P < 0.05
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lamina and facet joints, less postoperative pain and faster rehabilitation [7e11]. Ruetten et al. performed a prospective randomized controlled study of full-endoscopic interlaminar and transforaminal lumbar discectomy versus the conventional microsurgical technique for lumbar disc herniation [3]. They concluded that these two surgical techniques exhibit similar clinical therapeutic effects and that the endoscopic procedure resulted in a smaller epidural scar and smaller wound. Choi et al. reported PED can be an effective treatment for lumbar disc herniation, and it is associated with potential advantages, including a rapid recovery, improvements in back pain and disc height preservation compared with open lumbar microdiscectomy [11]. Yamashita et al. reported that repeat PED surgery for recurrence of LDH after PED is an effective method because of the minimal adhesion around the nerve [17]. PED is an atraumatic procedure for LDH and might be useful for the repeat recurrence LDH. 4.2. Low back pain and PED Patients with LDH often suffered from not only sciatic pain but also LBP. It has been reported that PED is used for chronic discogenic LBP [16,18,19]. The PED procedure is used in these studies, with the tear of the posterior annulus fibrosus modulated by a bipolar radiofrequency coagulator, known as the thermal annuloplasty technique. PED and thermal annuloplasty was shown to be effective for discogenic LBP. In our study, not only leg pain but also their discogenic LBP improved after PED without thermal annuloplasty. The precise pathophysiology is not clear from our study, but a decrease in the intradiscal pressure might be one of the causes of LBP reduction. Kambin et al. reported that the rapid decline of intradiscal pressure after percutaneous transforaminal nucleotomy appears to show good results for LDH patients [20]. Especially in young LDH patients such as athletes, intradiscal pressure tends to be high, and reduction of intradiscal pressure with percutaneous discectomy might be useful for young discogenic LBP patients [20e23]. Moreover, annular tear and leakage of the nucleus pulposus to the surface of the anulus fibrosus might induce an inflammatory reaction and LBP [24,25]. Leakage of the nucleus pulposus induces an immunoreaction and recruitment of the inflammatory cytokine and mediators such as tumor necrotic factor and interleukin. PED might be useful for discogenic LBP in young patients through reduction of the intradiscal pressure and extrusion of the nucleus pulposus from the surface of the anulus fibrosus, thus reducing inflammation. 4.3. Return to play To athletes, LDH leads to poor performance and inability to play sports because of LBP and leg pain. Athletes hope to return to sporting activity as quickly as possible, because a delay may result in loss of performance condition and relegation from the regular status or team position. Some studies reported that patients with LDH in the general population improved both through surgery and usual conservative care in the long term [26,27]. However, athletes need to return to play their sports quickly and sometimes they need to undergo surgery, so therefore a less invasive surgical procedure is necessary, in order to preserve muscle and prevent bone damage such as PED [5,6]. However, reports on the effect of PED on LDH in athletes are rare. Sairyo et al. reported the efficacy of PED with thermal annuloplasty in 4 professional athletes [16]. They concluded that PED is a minimally invasive procedure especially for athletes. Abe et al. reported on foraminoplastic transforaminal PED in a rugby player, who returned to rugby practice 8 weeks after surgery and was able to play competition rugby 4 months after surgery [28]. In our study, all patients received athletic
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Fig. 1. Magnetic resonance image showed lumbar disc herniation at L4-5 before surgery (a: T2-weighted sagittal image, b: T2-weighted axial image). After surgery, lumbar disc herniation was removed (c: T2-weighted sagittal image, d: T2-weighted axial image).
rehabilitation after surgery and they could return to sporting activity 6 weeks after surgery depending on the extent of their recovery. In actual fact, 93% (20/21) returned to the same level of sporting activity as before the procedure, at an average of 9.2 weeks after PED. As for the return to play after lumbar surgery, a literature review showed 83.5% of the elite athletes who underwent microscopic lumbar discectomy for LDH returned to play [6]. Watkins et al. reported the average time from microscopic lumbar discectomy to return to play was 5.2 months (range: 1e15 months) for the entire group [5]. Yoshimoto et al. reported the mean period until complete return to competition after microscopic lumbar discectomy was 10.8 weeks (range: 5e16 weeks) [29]. However, the timing of the return to play after lumbar surgery is controversial and no definitive accurate timing advice for return to play after PED is given. We allowed patients to return to sporting activity 6 weeks after surgery depending on the extent of their recovery. All patients received sports rehabilitation with athletic trainers or physical therapists immediately after surgery. One week after PED, corestrengthening exercises commenced. This core stabilization program consists of coordination of the torso muscles, establishing a neutral position, and gaining isometric control of the torso's mobilization. Sports rehabilitation is an essential program to facilitate the return to previous sports activity. In conclusion, PED is a minimally invasive and effective surgical procedure for patients with LDH especially for athletes. The patients improved not only in terms of leg pain but also regarding their discogenic LBP. PED has the benefits of surgery under local anesthesia, preservation of normal posterior structures, less postoperative pain and a faster return to sports. 5. Conclusions PED is a minimally invasive and effective procedure for patients with LDH, especially in athletes. Not only the patients' leg pain but also their discogenic LBP improved. PED could offer a high possibility of an early return to the same level of sports activity. Conflict of interest The authors confirm that this article content has no conflict of interest. No funds were received in support of this work. References [1] Weber H. Lumbar disc herniation: a controlled, prospective study with ten years of observation. Spine 1983 Mar;8(2):131e40.
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