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      Comparison of Percutaneous Endoscopic Lumbar Discectomy with Minimally Invasive Transforaminal Lumbar Interbody Fusion as a Revision Surgery for Recurrent Lumbar Disc Herniation after Percutaneous Endoscopic Lumbar Discectomy

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          The purpose of this study was to compare the outcomes between percutaneous endoscopic lumbar discectomy (PELD) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for the revision surgery for recurrent lumbar disc herniation (rLDH) after PELD surgery.

          Patients and Methods

          A total of 46 patients with rLDH were retrospectively assessed in this study. All the patients had received a PELD in Peking University First Hospital between January 2015 and June 2019, before they underwent a revision surgery by either PELD (n=24) or MIS-TLIF (n=22). The preoperative data, perioperative conditions, complications, recurrence condition, and clinical outcomes of the patients were compared between the two groups.


          Compared to the MIS-TLIF group, the PELD group had significantly shorter operative time, less intraoperative hemorrhage, and shorter postoperative hospitalization, but higher recurrence rate ( P<0.05). Complication rates were comparable between the two groups. Both groups had satisfactory clinical outcomes at a 12-month follow-up after the revision surgery. The PELD group also showed significantly lower visual analog scale (VAS) scores of back pain and Oswestry disability index (ODI) in one month after the revision surgery, whereas the difference was not detectable at six- and 12-month follow-ups.


          Both PELD and MIS-TLIF are effective as a revision surgery for rLDH after primary PELD. PELD is superior to MIS-TLIF in terms of operative time amount of intraoperative hemorrhage and postoperative hospitalization. However, its higher postoperative recurrence rate must be considered and patients should be well informed, when making a decision between the two surgical approaches.

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          Most cited references 47

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          Transforaminal posterolateral endoscopic discectomy with or without the combination of a low-dose chymopapain: a prospective randomized study in 280 consecutive cases.

          A prospective randomized study involving 280 consecutive cases of lumbar disc herniation managed either by an endoscopic discectomy alone or an endoscopic discectomy combined with an intradiscal injection of a low dose (1000 U) of chymopapain. To compare outcome, complications, and reherniations of both techniques. Despite a low complication rate, posterolateral endoscopic nucleotomy has made a lengthy evolution because of an assumed limited indication. Chemonucleolysis, however, proven to be safe and effective, has not continued to be accepted by the majority in the spinal community as microdiscectomy is considered to be more reliable. A total of 280 consecutive patients with a primary herniated, including sequestrated, lumbar disc with predominant leg pain, was randomized. A clinical follow-up was performed at 3 months, and at 1 and 2 years after the index operation with an extensive questionnaire, including the visual analog scale for pain and the MacNab criteria. The cohort integrity at 3 months was 100%, at 1 year 96%, and at 2 years 92%. At the 3-month evaluation, only minor complications were registered. At 1-year postoperatively, group 1 (endoscopy alone) had a recurrence rate of 6.9% compared to group 2 (the combination therapy), with a recurrence rate of 1.6%, which was a statistically significant difference in favor of the combination therapy (P = 0045). At the 2-year follow-up, group 1 reported that 85.4% had an excellent or good result, 6.9% a fair result, and 7.7% were not satisfied. At the 2-year follow-up, group 2 reported that 93.3% had an excellent or good result, 2.5% a fair result, and 4.2% were not satisfied. This outcome was statistically significant in favor of the group including chymopapain. There were no infections or patients with any form of permanent iatrogenic nerve damage, and no patients had a major complication. A high percentage of patient satisfaction could be obtained with a posterior lateral endoscopic discectomy for lumbar disc herniation, and a statistically significant improvement of the results was obtained when an intradiscal injection of 1000 U of chymopapain was added. There was a low recurrence rate with no major complications. The method can be applied in any type of lumbar disc herniation, including the L5-S1 level.
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            Percutaneous endoscopic lumbar discectomy for recurrent disc herniation: surgical technique, outcome, and prognostic factors of 43 consecutive cases.

            A retrospective study of 43 consecutive patients who underwent percutaneous endoscopic lumbar discectomy for recurrent disc herniation. To evaluate the efficacy of endoscopic discectomy for recurrent disc herniations and to determine the prognostic factors affecting surgical outcome. Repeated open discectomy with or without fusion has been the most common procedure for a recurrent lumbar disc herniation. There have been no reports published on the feasibility and prognostic factors of the endoscopic discectomy for recurrent disc herniation. The inclusion criteria were recurrent disc herniations at the same level, regardless of side, with a pain-free interval longer than 6 months after the conventional open discectomy. Posterolateral endoscopic laser-assisted disc excisions were performed under local anesthesia. The mean follow-up period was 31 months (24-39 months). Based on the MacNab criteria, 81.4% showed excellent or good outcomes. The mean visual analog scale decreased from 8.72 +/- 1.20 to 2.58 +/- 1.55 (P <0.0001). In our series, better outcomes were obtained in patients younger than 40 years (P = 0.035), patients with duration of symptoms of less than 3 months (P = 0.028), and patients without concurrent lateral recess stenosis (P = 0.007). Percutaneous endoscopic lumbar discectomy is effective for recurrent disc herniation in selected cases. The posterolateral approach through unscarred virgin tissue can prevent nerve injury and could preserve the spinal stability. Both foraminal and intracanalicular portions can be decompressed simultaneously.
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              Minimally invasive transforaminal lumbar interbody fusion: a review of techniques and outcomes.

              Review of published literature. To review the available medical literature reporting results after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) and evaluate functional and radiographic outcomes with those following open TLIF and open posterior lumbar interbody fusion (PLIF) procedures. Minimally invasive spine techniques aim to reduce approach-related surgical morbidity without compromising operative and clinical outcomes. MIS TLIF is increasingly being used for the management of various lumbar degenerative diseases. Despite the limited number of well-designed clinical studies, the available published data suggest potential advantages over its open posterior-approach lumbar interbody fusion counterparts. Such benefits include less intraoperative blood loss, less need for blood transfusions, shorter hospital course, and less postoperative pain. Literature examining posterior-approach interbody fusion techniques (PLIF, TLIF, and MIS TLIF) was collected using the National Center for Biotechnology Information database and PubMed/MEDLINE, and summarized for discussion. Literature reports of MIS TLIF generally show comparable or improved clinical outcomes when compared with those following open posterior interbody fusion techniques. Additionally, significantly less blood loss, hospital stay, and complications were generally reported, despite slightly longer duration of surgery, especially during early cases in a surgeon's experience. More studies designed to provide class I or II data will be needed in the future to further solidify the favorable results observed so far with the MIS TLIF procedure.

                Author and article information

                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                08 December 2020
                : 16
                : 1185-1193
                [1 ]Department of Orthopedics, Peking University First Hospital , Peking, People’s Republic of China
                Author notes
                Correspondence: Zhengrong Yu Department of Orthopedics, Peking University First Hospital , Xishiku Street No. 8, Xicheng District, Peking100034, People’s Republic of ChinaTel +86-10-8357-2655 Email yuzronline@163.com
                © 2020 Wang and Yu.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                Page count
                Figures: 2, Tables: 7, References: 48, Pages: 9
                Original Research


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