Eight Surgical Interventions for Lumbar Disc Herniation: A Network Pooling Evaluation

The aim of this network meta-analysis (NMA) was to compare the complication rates of discectomy/microdiscectomy, percutaneous laser disc decompression (PLDD), percutaneous endoscopic lumbar discectomy (PELD), microendoscopic discectomy (MED), and tubular discectomy for symptomatic lumbar disc herniation (LDH). We searched three online databases for randomized controlled trials (RCTs). Overall complication rates, complication rates per general and modified Clavien-Dindo classification schemes, and reoperation rates were considered as primary outcomes. Odds ratio with 95% confidence intervals for direct comparisons and 95% credible intervals for NMA results were reported. Surface under cumulative ranking curve (SUCRA) was used to estimate ranks for each discectomy technique based on the complication rates. In total, 18 RCTs with 2273 patients were included in this study. Our results showed that there was no significant difference in any of the pairwise comparisons. PELD (SUCRA: 0.856) ranked the lowest for overall complication rates. Discectomy/microdiscectomy (SUCRA: 0.599) and PELD (SUCRA: 0.939) ranked the lowest for intraoperative and post-operative complication rates, respectively. Concerning modified Clavien-Dindo classification scheme, PELD (SUCRA: 0.803), MED (SUCRA: 0.730), and PLDD (SUCRA: 0.605) ranked the lowest for the occurrence of type I, II, and III complications, respectively. Tubular discectomy (SUCRA: 0.699) ranked the lowest for reoperation rates. The results of this NMA suggest that discectomy/microdiscectomy and PELD are the safest procedures for LDH with minimal intraoperative and post-operative complications, respectively. PELD, MED, and PLDD are the safest procedures for LDH in terms of minimal rates for complications necessitating conservative, pharmacological, and surgical treatment, respectively. These slides can be retrieved under Electronic Supplementary Material.

Background/Objectives: The treatment for lumbar disc herniation (LDH) is surgical discectomy. This surgery may enhance spinal instability and exacerbate disc degeneration. The most common treatment options include microdiscectomy (MD), interspinous process device (IPD) implantation, and percutaneous endoscopic lumbar discectomy (PELD). As few studies have compared these three procedures, this study focused on collecting data on the clinical, functional, and imaging outcomes of surgery for symptomatic LDH. Methods: This is a retrospective, transverse, and analytical study, with a total of 383 patients who received operations for symptomatic LDH between 2018 and 2022. Medical information from the charts of these patients was collected. The results were followed up on for a minimum of one year by collecting responses from several questionnaires and clinical data, including patients' scores on the visual analogue scale (VAS), Oswestry Disability Index (ODI), and symptomatic improvement score (SIS), as well as wound size, blood loss, hospital stay, postoperative disc change, and complications. Results: At the end of data collection, the VAS and ODI scores all showed significant improvement following these three procedures (p < 0.01). The SISs were all ranked as good (8.1, 8.5, and 7.9) post-surgery. PELD was a minimally invasive procedure that resulted in the smallest wound size (0.82 cm), minimal blood loss (21 mL), and a short hospital stay (4.2 days). A substantial pre-/postoperative change in disc height was noted in the MD (-17%) and PELD (-15%) groups. The complication rates were similar among the three groups (3%, 5%, and 5.6%). Conclusions: IPD implantation and PELD yielded outcomes comparable to those of conventional MD for symptomatic relief and functional recovery. Although the complication rates were similar, the postoperative complications were quite different from those of the other procedures. PELD resulted in rapid recovery and minimal invasion, and IPD implantation showed a good ability to preserve disc height and spinal stability; however, the clinical relevance of these findings in disc degeneration remains controversial.

<title>Abstract</title> Purpose To systematically compare the clinical outcomes and learning curves of unilateral biportal endoscopy (UBE) and percutaneous endoscopic lumbar discectomy (PELD) in the treatment of far lateral lumbar disc herniation (FLLDH). Methods A retrospective analysis was conducted on 122 patients with FLLDH who underwent spinal endoscopic surgery between January 2022 and July 2024, including 62 cases in the PELD group and 60 cases in the UBE group. All procedures were performed by the same minimally invasive spine surgery team. Perioperative parameters (operative time, intraoperative blood loss, foraminal area, postoperative hospital stay, total cost), visual analogue scale (VAS) scores, Oswestry Disability Index (ODI), and modified Macnab criteria were compared. Learning curves were analyzed using cumulative sum (CUSUM) with operative time as the core variable. All patients were followed for at least 12 months. Results Baseline characteristics were comparable between groups ( <italic>P</italic> &gt; 0.05). Both PELD and UBE significantly improved lumbar and leg pain ( <italic>P</italic> &lt; 0.05). No significant differences were found in VAS or ODI scores between the two groups preoperatively, at 3 months, or at 12 months postoperatively ( <italic>P</italic> &gt; 0.05). Only on postoperative day 1 did the PELD group show a lower VAS back pain score ( <italic>P</italic> &lt; 0.05). The excellent/good rate based on modified Macnab criteria did not differ significantly ( <italic>P</italic> &gt; 0.05). Perioperative indicators, including operative time, intraoperative and hidden blood loss, and total cost, were all significantly more favourable in the PELD group ( <italic>P</italic> &lt; 0.001). No differences were observed in intraoperative fluoroscopy frequency or foraminal cross-sectional area ( <italic>P</italic> &gt; 0.05). CUSUM analysis indicated that proficiency was achieved after 24 UBE cases and 38 PELD cases. All complications resolved with conservative treatment. Conclusion Both UBE and PELD are safe and effective for treating FLLDH. PELD offers advantages in perioperative minimally invasive characteristics and cost-efficacy, whereas UBE features a shorter learning curve, facilitating more rapid surgical mastery.

Comparison of Outcomes of Percutaneous Endoscopic Lumbar Discectomy and Open Lumbar Microdiscectomy for Young Adults: A Retrospective Matched Cohort Study

The purpose of this research was to investigate the outcomes between unilateral biportal endoscopic discectomy (UBE) and percutaneous endoscopic lumbar discectomy (PELD) for the single L4/5-level lumbar disk herniation (sLDH). From January 2018 to January 2021, a total of 40 patients with sLDH were retrospectively analyzed in this study. All the patients had received spinal surgeries in Affiliated Hospital of Nantong University and Affiliated Nantong Hospital 3 of Nantong University. Among them, 20 patients were treated with PELD (PELD group), and 20 patients were treated with UBE discectomy (UBE group). Postoperative length of hospital stay, estimated blood loss, operation time, and clinical complications of the patients were compared between the two groups. The visual analog scale (VAS) and Oswestry Disability Index (ODI) were measured before surgeries and 3days, 1, and 6months after surgeries. Compared with the UBE group, the PELD group had obviously less intraoperative blood loss, shorter operative time, and shorter hospital stay. The differences in the rate of complications were not statistically significant between the two groups. The VAS score and the ODI score of the two groups had a great reduction after operation. In addition, both the groups had satisfactory clinical outcome; the VAS score and ODI of the PELD group decreased more obviously. The UBE for sLDH yielded similar clinical outcomes to PELD as minimally invasive surgeries; however, PELD is superior to UBE in terms of intraoperative blood loss, operative time, postoperative hospitalization, and short-term postoperative pain relief. The advantages and disadvantages of the two surgeries should be circumspectly balanced when evaluating a patient for a minimally invasive surgery for sLDH, selecting the most appropriate surgical method for patients.

Introduction Despite all of the technical refinements, surgical treatment of herniated discs still remains controversial. The objective of the current prospective randomized study was to compare the outcome of patients with persistent sciatica secondary to lumbar disc herniation treated with either open discectomy (OD) or microendoscopic discectomy (MED) technique. Patients and Methods We performed a prospective controlled randomized study of 40 patients with sciatica caused by lumbar disc herniations nonresponsive to conservative treatment who underwent OD or MED with a 24-month follow-up period. Pre- and postoperative neurological status, pain, and functional outcome were evaluated. Other studied variables were the duration of the procedure, blood loss, time of hospital stay, and time to return to work. Statistical analysis with a p value less than 0.005 was performed. Results The only statistically significant differences found were for size of the incision, length of hospital stay, and operative time. The former two were greater in the OD group ( p &lt; 0.01 and p = 0.05, respectively), and the latter was greater in the MED group ( p &lt; 0.01). Conclusion The few parameters that were found to be statistically significant between the groups did not affect the overall outcome. In the current series, the final clinical and neurological results were similarly satisfactory in both the OD and the MED groups.

In recent years, with improved living standards, adolescent obesity has been increasingly studied. The incidence of lumbar disc herniation (LDH) in obese adolescents is increasing yearly. No clinical studies have reported the use of percutaneous endoscopic lumbar discectomy (PELD) in obese adolescent lumbar disc herniation (ALDH) patients. This study evaluated the preliminary surgical outcomes of PELD in obese ALDH patients. Fifty-one ALDH patients underwent single-level PELD surgery between January 2014 and January 2020. Patients were divided into an obese group and a normal group. Patient characteristics and surgical variables were compared between the two groups. The VAS, ODI, and SF-36 scales were used preoperatively and postoperatively to evaluate the clinical efficacy. In this study, 19 patients were included in the obese group, and 28 were included in the normal group. There was no significant difference in age, sex, duration of low back pain, duration of leg pain, or operative level between the obese and normal groups preoperatively. The obese group had a longer operative time (OT) (101.9 ± 9.0 min vs. 84.3 ± 11.0 min, P < 0.001), more fluoroscopy exposures (41.0 ± 5.8 vs. 31.6 ± 7.0, P < 0.001) and a longer time to ambulation (29.9 ± 4.0 vs. 25.0 ± 2.9, p < 0.001) than the normal group. The groups did not significantly differ in complications. The VAS score for back and leg pain and the ODI and SF-36 score for functional status improved significantly postoperatively. The PELD procedure is a safe and feasible method for treating LDH in obese adolescents. Obese ALDH patients require a longer OT, more fluoroscopy exposures and a longer time to get out of bed than normal ALDH patients. However, PELD yields similar clinical outcomes in obese and normal ALDH patients.

OBJECTIVE This study aimed to evaluate the clinical outcomes of percutaneous endoscopic transforaminal discectomy (PETD), microendoscopic discectomy (MED), and microdiscectomy (MD) for treatment of symptomatic lumbar disc herniation (LDH). METHODS One hundred ninety-two patients with symptomatic LDH at L3-4 and L4-5 were included in this study. The mean (± SD) age of patients was 34.2 ± 2.6 years (range 18-62 years). The patients were divided into groups as follows: group A was treated with PETD and included 60 patients (31 men and 29 women) with a mean age of 36.2 years; group B was treated with MED and included 63 patients (32 men and 31 women) with a mean age of 33.1 years; and group C was treated with MD and included 69 patients (36 men and 33 women) with a mean age of 34.0 years. The Japanese Orthopaedic Association (JOA) scale for low-back pain (LBP), Oswestry Disability Index (ODI), creatine phosphokinase activity 3 days after surgery, and visual analog scale (VAS) scores for LBP and leg pain were used for evaluation of clinical results. RESULTS There were no significant differences in mean preoperative JOA score, ODI score, and VAS scores for LBP and leg pain among groups A, B, and C. Incision length, duration of the operation, blood loss, creatine phosphokinase, length of hospital stay, and postoperative incision pain according to the VAS were best in the PETD group (p < 0.05). The number of seconds of intraoperative fluoroscopy was highest in the PETD group (p < 0.05), whereas there was no difference between the MED and MD groups. Three cases from the MED group and 2 cases from the MD group had an intraoperative durotomy. No CSF leakage was observed after surgery. One case from the MED group and 3 cases from the MD group had incision infections. There were no neurological deficits related to the surgeries in any of the groups. Fifty-five (91.6%), 59 (93.7%), and 62 patients (89.9%) had at least 2 years of follow-up in groups A, B, and C, respectively. At the last follow-up, JOA scores, VAS scores of LBP and leg pain, and ODI scores were significantly better than preoperative correlates in all groups. There were no differences among the 3 groups in JOA scores, JOA recovery rate, ODI scores, and VAS scores for leg pain. The VAS score for LBP was best in the PETD group (p < 0.05). No lumbar instability was observed in any group. Three cases (5.5%) in the PETD group had recurrent LDH, and 2 recurrent cases (3.4%) were confirmed in the MED group. CONCLUSIONS PETD, MED, and MD were all reliable techniques for the treatment of symptomatic LDH. With a restricted indication, PETD can result in rapid recovery and better clinical results after at least 2 years of follow-up.

Radiation Exposure and Operation Time in Percutaneous Endoscopic Lumbar Discectomy Using Fluoroscopy-Based Navigation System

Percutaneous endoscopic lumbar discectomy (PELD) is a minimally invasive spinal technique that has several advantages over open discectomy, including less paravertebral muscle injury, preservation of bony structure, and rapid recovery. PELD has gained popularity for removal of herniated disc (HD) material over the past few years since Kambin introduced the percutaneous posterolateral approach in 1983. Remarkable evolution of endoscopic techniques and instrumentation leads to successful outcomes comparable to conventional open surgery. PELD has been applied to various types of disc herniation and the indication has been expanded. I propose various strategies for PELD according to various types of disc herniation.

Microendoscopic discectomy (MED) has been accepted as a minimally invasive procedure for lumbar discectomy because of the small skin incision and short hospital stay required for this surgery. However, there are few objective laboratory data to confirm the reduced systemic responses in the early phase after this procedure. In order to substantiate the reduced invasiveness of MED compared to microdiscectomy (MD) or procedures involved in one-level unilateral laminotomy, the invasiveness of each surgical procedure was evaluated by measuring serum levels of biochemical parameters reflective of a post-operative inflammatory reaction and damage to the paravertebral muscles. Thirty-three patients who underwent lumbar discectomy or one-level unilateral laminotomy (MED in 15 cases, MD in 11 cases and one-level unilateral laminotomy in 7 cases with lumbar spinal canal stenosis) were included in this study. The serum levels of C-reactive protein (CRP) and creatine phosphokinase (CPK) were measured at 24 h after operation. Interleukin-6 (IL-6) and Interleukin-10 (IL-10) were measured at 2, 4, 8 and -24 h following the surgery to monitor the inflammatory response to the respective surgery. The post-operative serum CRP levels from both the MD and MED groups were significantly lower than those from the open laminotomy group. However, there was no significant difference in these serum levels between the MED and MD groups. The levels of IL-6 and IL-10 in the MED group during the first post-operative day were also significantly lower than those in the laminotomy group. When the MED and MD groups were compared, the IL-6 levels in the MED group were lower than in MD group at 2, 4 and 8 h after surgery, but the differences were not statistically significant. However, the level was significantly lower in the MED group at 24 h after surgery. In terms of IL-10, no significant difference was noted between the MED and MD groups over the study period. The changes in serum levels of post-operative inflammatory: markers (CRP, IL-6 and IL-10) in the early phase indicated reduced inflammatory reactions in MED as well as in MD when compared with classical open unilateral laminotomy. These data draw a direct link between the lower level of the inflammatory response and reduced invasiveness of MED. However, an indicator for muscle damage (CPK) appeared not to be affected by the type of surgical procedure used to correct disc herniation.

PurposeTo evaluate the clinical features of and risk factors for recurrent lumbar disc herniation (rLDH) after percutaneous endoscopic lumbar discectomy (PELD) in our clinical practice.MethodsA total of 942 consecutive patients who underwent single-level PELD from January 2013 to August 2019 were included. Patients were divided into the recurrence group and the nonrecurrence group. Patient characteristics, radiographic parameters and surgical variables were compared between the two groups. Univariate analysis and multiple logistic regression analysis were adopted to determine the risk factors for recurrence after PELD.ResultsThe prevalence of rLDH was 6.05%. Age, sex, tobacco use, duration of low back pain, body mass index (BMI), occupational lifting, herniated disc type, facet joint degeneration, operation time and time to ambulation were significantly different between the two groups. Univariate analysis showed that age (P < 0.001), sex (P = 0.019), BMI (P = 0.001), current smoking (P < 0.001), occupational lifting (P < 0.001), facet joint degeneration (P = 0.001), operation time (P = 0.002), and time to ambulation (P < 0.001) could be significantly associated with the incidence of rLDH after PELD. Multivariate analysis suggested that an older age (P < 0.001), the male sex (P = 0.017), a high BMI (P < 0.001), heavy work (P = 0.003), grade II facet joint degeneration (P < 0.001) and early ambulation (P < 0.001) were significantly related to rLDH after PELD.ConclusionsAn older age, the male sex, a higher BMI, heavy work, grade II facet joint degeneration, and early ambulation are independent significant risk factors for rLDH after PELD. Great importance should be attached to these risk factors to prevent rLDH. We suggest that patients control their weight, avoid heavy work, ambulate at an appropriate time, and perform strengthening rehabilitation exercises to reduce the incidence of rLDH.

ObjectiveThe purpose of the present study was to discuss a new surgical strategy that combines percutaneous endoscopic transforaminal discectomy (PETD) with percutaneous endoscopic interlaminar discectomy (PEID) for L4/5 and L5/S1 two‐level disc herniation.MethodsThis was a retrospective study. A total of 19 patients with L4/5 and L5/S1 two‐level lumbar disc herniation (LDH) who underwent percutaneous endoscopic lumbar discectomy (PELD) in our hospital from January 2015 to June 2016 were retrospectively examined. The average age of these 19 patients was 42.21 ± 14.88 years old, including 12 men and 7 women. One experienced surgeon who had carried out more than 3000 lumbar surgeries performed PELD for these patients. During the PELD surgery, the transforaminal approach was adopted for L4/5 level disc herniation and the interlaminar approach was adopted for L5/S1 level disc herniation. The demographic data, operation time (min), fluoroscopy times, hospital stay (days), and complications were recorded and analyzed. The visual analogue scale (VAS), Oswestry disability index (ODI) scores, and the modified MacNab criteria were used to evaluate the surgical outcomes. MRI was conducted to evaluate the radiographic improvement.ResultsAll patients underwent PELD via the transforaminal approach combined with the interlaminar approach successfully and achieved satisfactory efficacy. The follow‐up points were 3, 12, and 18 months. The average hospital stay (days) and the average follow up (months) were 3.32 ± 0.98 and 18.63 ± 3.84, respectively. The operation time and fluoroscopy times were 85.79 ± 12.90 min and 39.05 ± 4.59 times, respectively. The fluoroscopy times (frequency) for L4/5 and L5/S1 were 26.95 ± 6.41 and 12.11 ± 3.49 (t = 7.00, P < 0.05). Furthermore, there was no significant difference for fluoroscopy times between male and female patients (t = 0.89, P = 0.99). The preoperative back pain (VAS‐Back) and the last follow‐up VAS‐Back were 5.58 ± 2.01 and 2.37 ± 1.01, respectively (t = 7.14, P < 0.05). The preoperative leg pain (VAS‐Leg) and the last follow‐up VAS‐Leg were 7.00 ± 1.56 and 1.63 ± 1.01, respectively (t = 20.97, P < 0.05). There were significant differences between preoperative VAS‐Back and the last follow‐up VAS‐Back in men (t = 4.61, P < 0.05) and women (t = 6.57, P < 0.05). In addition, there was significant differences between preoperative VAS‐Leg and the last follow‐up VAS‐Leg in men (t = 13.48, P < 0.05) and women (t = 26.87, P < 0.05). There were significant differences between preoperative ODI scores (44.84 ± 10.82%) and the last follow‐up ODI scores (11.12 ± 5.80%) (t = 10.92, P < 0.05). Preoperative ODI scores and the last follow‐up ODI scores were significantly different for men (t = 8.80, P < 0.05) and women (t = 6.63, P < 0.05). All patients received significant pain relief and functional improvement after the surgery. Except for two cases of postoperative dysesthesia and one dural tear, no severe complications occurred. The dysesthesia symptoms of these two patients disappeared within 1 week with the application of dexamethasone and neurotrophic drugs and the dural tear case also recovered well as the dural laceration was small. No poor results were reported and 89.47% of patients achieved excellent or good recovery.ConclusionPercutaneous endoscopic lumbar discectomy via the transforaminal approach combined with the interlaminar approach under epidural anesthesia can treat L4/5 and L5/S1 two‐level disc herniation safely and effectively.

BackgroundAlthough percutaneous endoscopic lumbar discectomy (PELD) is increasingly being used to treat lumbar degenerative disease, the treatment of elderly patients with lumbar spinal stenosis (LSS) involves considerable uncertainty. The purpose of this study was to evaluate the safety and effectiveness of PELD for the treatment of LSS in elderly patients aged 65 years or older.MethodsIn this retrospective review, 136 patients aged 65 years or older who underwent PELD to treat LSS were evaluated. The patients were divided into two groups, group A (ages 65–74) and group B (age ≥ 75), and perioperative data were analyzed. The Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS) score, and MacNab classification were used to evaluate postoperative clinical efficacy.ResultsAll patients successfully underwent the operation with satisfactory treatment outcomes. Compared to preoperative scores, the self-reported scores or pain while performing daily activities were significantly improved in both treatment groups (P < 0.05). No statistically significant between-group differences were observed in operation time, intraoperative blood loss, postoperative bed rest, and postoperative hospital stay (P > 0.05). The overall postoperative complication rate was similar between the two groups. Moreover, no statistically significant differences in VAS-back pain scores, VAS-leg pain scores, JOA scores, and MacNab classification were found between the groups at the 3-month and 1.5-year follow-up examinations (P > 0.05).ConclusionPELD is safe and effective for the treatment of LSS in elderly patients. Age is not a contraindication for decompressive lumbar spine surgery. PELD has advantages such as reduced trauma, fewer anesthesia-related complications, and a fast postoperative recovery. Elderly patients should be considered good candidates for lumbar decompression surgery using minimally invasive techniques.

Study DesignThis study is a meta-analysis of randomized controlled trials (RCTs) and observational studies.ObjectiveLumbar disc herniation (LDH) often requires surgery, with microdiscectomy (MD) being common. This study compares Unilateral Biportal Endoscopic Discectomy (UBED) to conventional and tubular MD for LDH treatment.MethodsPubMed, Cochrane Central, and ScienceDirect were searched up to May 2025. Mean differences (MDs) and risk ratios (RRs) were pooled with a random effects model using Review Manager. Quality was assessed using the Cochrane risk of bias tool and the Newcastle-Ottawa Scale. Publication bias was evaluated with funnel plots and Egger's regression test.ResultsThirteen studies (11 observational studies and 2 RCTs), pooling 1369 patients, were included. UBED was associated with decreased 1-3 days post-operative (MD: -0.81; 95% CI: [-1.48, -0.14]; P = 0.02) and 12months post-operative (MD: -0.37; 95% CI: [-0.74, -0.01]; P = 0.04) VAS back pain scores, 12months post-operative ODI scores (MD: -1.32; 95% CI: [-2.44, -0.19]; P = 0.02), estimated blood loss (MD: -74.42; 95% CI: [-114.11, -34.73]; P = 0.0002), and hospital stay (MD: -1.81; 95% CI: [-2.99, -0.63]; P = 0.003) compared to conventional MD although the operative time was high (MD: 9.07; 95% CI: [1.66, 16.48]; P = 0.02). Concurrently, the 12months post-operative VAS back pain score (MD: -0.42; 95% CI: [-1.40, 0.56]; P = 0.40) and ODI score (MD: 1.39; 95% CI: [-2.80, 5.58]; P = 0.52) along with the operative time (MD: 21.80; 95% CI: [-26.31, 69.92]; P = 0.37) and hospital stay (MD: 0.02; 95% CI: [-0.30, 0.33]; P = 0.92) were comparable between the UBED and tubular MD. The VAS leg pain scores were comparable between UBED and both conventional and tubular MD.ConclusionUBED may be associated with reduced early and long-term back pain, disability, blood loss, and hospital stays compared to conventional MD, but has longer surgery times, with comparable outcomes to tubular MD. More large-scale RCTs are required to validate these results.