Higher risk of dural tears and recurrent herniation with lumbar micro-endoscopic discectomy

Abstract

Existing studies on micro-endoscopic lumbar discectomy report similar outcomes to those of open and microdiscectomy and conflicting results on complications. We designed a randomised controlled trial to investigate the hypothesis of different outcomes and complications obtainable with the three techniques. 240 patients aged 18-65 years affected by posterior lumbar disc herniation and symptoms lasting over 6 weeks of conservative management were randomised to micro-endoscopic (group 1), micro (group 2) or open (group 3) discectomy. Exclusion criteria were less than 6 weeks of pain duration, cauda equina compromise, foraminal or extra-foraminal herniations, spinal stenosis, malignancy, previous spinal surgery, spinal deformity, concurrent infection and rheumatic disease. Surgery and follow-up were made at a single Institution. A biomedical researcher independently collected and reviewed the data. ODI, back and leg VAS and SF-36 were the outcome measures used preoperatively, postoperatively and at 6-, 12-and 24-month follow-up. 212/240 (91%) patients completed the 24-month follow-up period. VAS back and leg, ODI and SF36 scores showed clinically and statistically significant improvements within groups without significant difference among groups throughout follow-up. Dural tears, root injuries and recurrent herniations were significantly more common in group 1. Wound infections were similar in group 2 and 3, but did not affect patients in group 1. Overall costs were significantly higher in group 1 and lower in group 3. In conclusion, outcome measures are equivalent 2 years following lumbar discectomy with micro-endoscopy, microscopy or open technique, but severe complications are more likely and costs higher with micro-endoscopy.

Recovery of muscle strength after microdiscectomy for lumbar disc herniation: a prospective cohort study with 1-year follow-up

“…The surgical method used in this study, microdiscectomy, seems to be the preferred method in many publications [13][14][15][16][17], and has fewer complications than other methods [18]. This study shows that 75% of the patients with limb paresis due to herniated lumbar disc had full recovery 12 months after micro discectomy.…”

Lumbar microdiscectomy complication rates: a systematic review and meta-analysis

“…2,3,9,[17][18][19]21,25,26,28,33,36,[41][42][43]45,49,[52][53][54][56][57][58]61 MED techniques employ a longitudinal paramedian incision through which a tubular retractor is placed and visualization is achieved through an endoscope. 2,6,10,13,19,24,25,29,36,46,51,53,57,60,62,64 Percutaneous discectomy entails placing a sheath directly into the disc space via a transforaminal approach, extraforaminal approach, or interlaminar approach and then using a suction/debrider or chemical injection to remove the disc. 1,11,12,23,30,37,44,50 To assess the risk of bias for each study, 3 reviewers (M.F.S., J.J.X., and E.Y.T.)…”

Tubular microdiscectomy: techniques, complication avoidance, and review of the literature

“…17 In contrast, in a randomized controlled trial, Teli et al demonstrated no difference in overall complications in the tubular microdiscectomy group but did demonstrate increased CSF leaks. 29 Of note, no CSF leaks in the tubular group required operative revision, probably due to the largely intact paraspinal musculature, which eliminates potential space for CSF fistulas to persist. Interestingly, there were no infections in the tubular group, compared with 4%-5% in the standard group.…”

“…17,25,29 In contrast, the trial conducted by Ryang et al demonstrated no difference in operating times. 26 Multiple retrospective studies and a meta-analysis support similar operating times for the tubular and standard groups.…”

“…The trials by Righesso et al and Teli et al also demonstrated no difference in VAS or ODI scores in either group with 2 years of follow-up. 25, 29 Ryang et al demonstrated no difference in VAS, ODI, or 36-Item Short Form Health Survey (SF-36) scores at 6 months after surgery in an additional randomized controlled trial. 26 Level I evidence suggests that tubular microdiscectomy is associated with outcomes similar to those of standard microdiscectomy, particularly in studies in which the procedure is used as originally described.…”