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Minimally invasive surgery for lumbar disc herniation: a systematic review and meta-analysis

European Spine Journal volume 23, pages 1021–1043 (2014)Cite this article

Abstract

Purpose

Assessing the benefits of surgical treatments for sciatica is critical for clinical and policy decision-making. To compare minimally invasive (MI) and conventional microdiscectomy (MD) for patients with sciatica due to lumbar disc herniation.

Methods

A systematic review and meta-analysis of controlled clinical trials including patients with sciatica due to lumbar disc herniation. Conventional microdiscectomy was compared separately with: (1) Interlaminar MI discectomy (ILMI vs. MD); (2) Transforaminal MI discectomy (TFMI vs. MD). Outcomes: Back pain, leg pain, function, improvement, work status, operative time, blood loss, length of hospital stay, complications, reoperations, analgesics and cost outcomes were extracted and risk of bias assessed. Pooled effect estimates were calculated using random effect meta-analysis.

Results

Twenty-nine studies, 16 RCTs and 13 non-randomised studies (n = 4,472), were included. Clinical outcomes were not different between the surgery types. There is low quality evidence that ILMI takes 11 min longer, results in 52 ml less blood loss and reduces mean length of hospital stay by 1.5 days. There were no differences in complications or reoperations. The main limitations were high risk of bias, low number of studies and small sample sizes comparing TF with MD.

Conclusions

There is moderate to low quality evidence of no differences in clinical outcomes between MI surgery and conventional microdiscectomy for patients with sciatica due to lumbar disc herniation. Studies comparing transforaminal MI with conventional surgery with sufficient sample size and methodological robustness are lacking.

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References

  1. Konstantinou K, Dunn KM (2008) Sciatica: review of epidemiological studies and prevalence estimates. Spine 33(22):2464–2472

    Article  PubMed  Google Scholar 

  2. Health Council of the Netherlands. (1999) Management of the lumbosacral radicular syndrome (sciatica). Health Council of the Netherlands publication no. 1999/18

  3. Gibson J, Waddell G (2007) Surgical interventions for lumbar disc prolapse. Cochrane Database Systematic Reviews 1:CD001350

  4. Higgins JPT, Green S (2011) Cochrane Handbook for Systematic Reviews of Interventions

  5. Guyatt GH, Oxman AD, Vist G, Kunz R, Falck-Ytter Y, Alonso-Coellof P, Schunemann HJ (2008) Rating quality of evidence and strength of recommendations GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. Br Med J 336:924–926

    Article  Google Scholar 

  6. Arts MP, Brand R, Van Den Akker ME, Koes BW, Bartels RHMA, Peul WC (2009) Tubular diskectomy vs conventional microdiskectomy for sciatica: a randomized controlled trial. JAMA 302(2):149–158

    Article  CAS  PubMed  Google Scholar 

  7. Bennis S, Scarone P, Lepeintre JF, Aldea S, Gaillard S (2009) Transtubular versus microsurgical approach for single lumbar disc herniation: a prospective study. Eur J Orthop Surg Traumatol 19(8):535–540

    Article  Google Scholar 

  8. Brock M, Kunkel P, Papavero L (2008) Lumbar microdiscectomy: subperiosteal versus transmuscular approach and influence on the early postoperative analgesic consumption. Eur Spine J 17(4):518–522

    Article  PubMed Central  PubMed  Google Scholar 

  9. Franke J, Greiner-Perth R, Boehm H, Mahlfeld K, Grasshoff H, Allam Y, Awiszus F (2009) Comparison of a minimally invasive procedure versus standard microscopic discotomy: a prospective randomised controlled clinical trial. Eur Spine J 18(7):992–1000

    Article  PubMed Central  PubMed  Google Scholar 

  10. Garg B, Nagraja UB, Jayaswal A (2011) Microendoscopic versus open discectomy for lumbar disc herniation: a prospective randomised study. J Orthop Surg 19:30–34

    Google Scholar 

  11. German JW, Adamo MA, Hoppenot RG, Blossom JH, Nagle HA (2008) Perioperative results following lumbar discectomy: comparison of minimally invasive discectomy and standard microdiscectomy. Neurosurg Focus 25(100896471):E20

    Article  PubMed  Google Scholar 

  12. Harrington JF, French P (2008) Open versus minimally invasive lumbar microdiscectomy: comparison of operative times, length of hospital stay, narcotic use and complications. Minim Invasive Neurosurg 51(1):30–35

    Article  CAS  PubMed  Google Scholar 

  13. Huang TJ, Hsu RWW, Li YY, Cheng CC (2005) Less systemic cytokine response in patients following microendoscopic versus open lumbar discectomy. J Orthop Res 23(2):406–411

    Article  CAS  PubMed  Google Scholar 

  14. Lau D, Han SJ, Lee JG, Lu DC, Chou D (2011) Minimally invasive compared to open microdiscectomy for lumbar disc herniation. J Clin Neurosci 18(1):81–84

    Article  PubMed  Google Scholar 

  15. Martin-Laez R, Martinez-Agueros JA, Suarez-Fernandez D, Montiaga-Nunez F, Vazquez-Barquero A (2012) Complications of endoscopic microdiscectomy using the EASYGO! system: is there any difference with conventional discectomy during the learning-curve period? Acta Neurochir Wien 154(6):1023–1032

    Article  PubMed  Google Scholar 

  16. Muramatsu K, Hachiya Y, Morita C (2001) Postoperative magnetic resonance imaging of lumbar disc herniation: comparison of microendoscopic discectomy and love’s method. Spine 26(14):1599–1605

    Article  CAS  PubMed  Google Scholar 

  17. Nakagawa H, Kamimura M, Uchiyama S, Takahara K, Itsubo T, Miyasaka T (2003) Microendoscopic discectomy (MED) for lumbar disc prolapse. J Clin Neurosci 10(2):231–235

    Article  PubMed  Google Scholar 

  18. Righesso O, Falavigna A, Avanzi O (2007) Comparison of open discectomy with microendoscopic discectomy in lumbar disc herniations: results of a randomized controlled trial. Neurosurgery 61(3):545–549

    Article  PubMed  Google Scholar 

  19. Ryang YM, Oertel MF, Mayfrank L, Gilsbach JM, Rohde V (2008) Standard open microdiscectomy versus minimal access trocar microdiscectomy: results of a prospective randomized study. Neurosurgery 62(1):174–181

    Article  PubMed  Google Scholar 

  20. Sasaoka R, Nakamura H, Konishi S, Nagayama R, Suzuki E, Terai H, Takaoka K (2006) Objective assessment of reduced invasiveness in MED: compared with conventional one-level laminotomy. Eur Spine J 15(5):577–582

    Article  PubMed Central  PubMed  Google Scholar 

  21. Schick U, Dohnert J, Richter A, Konig A, Vitzthum H (2002) Microendoscopic lumbar discectomy versus open surgery: an intraoperative EMG study. Eur Spine J 11(1):20–26

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  22. Schizas C, Tsiridis E, Saksena J (2005) Microendoscopic discectomy compared with standard microsurgical discectomy for treatment of uncontained or large contained disc herniations. Neurosurgery 57:357–360

    Article  PubMed  Google Scholar 

  23. Shin D, Kim KN, Shin HC, Yoon DH (2008) The efficacy of microendoscopic discectomy in reducing iatrogenic muscle injury. J Neurosurg Spine 8:39

    Article  PubMed  Google Scholar 

  24. Teli M, Lovi A, Brayda-Bruno M, Zagra A, Corriero A, Giudici F, Minoia L (2010) Higher risk of dural tears and recurrent herniation with lumbar micro-endoscopic discectomy. Eur Spine J 19(3):443–450

    Article  PubMed Central  PubMed  Google Scholar 

  25. Toyone T, Tanaka T, Kato D, Kaneyama R (2004) Low-back pain following surgery for lumbar disc herniation. A prospective study. J Bone Joint Surg Am 86-A:893–896

    PubMed  Google Scholar 

  26. Wu X, Zhuang S, Mao Z, Chen H (2006) Microendoscopic discectomy for lumbar disc herniation: surgical technique and outcome in 873 consecutive cases. Spine 31(23):2689–2694

    Article  PubMed  Google Scholar 

  27. Hermantin FU, Peters T, Quartararo L, Kambin P (1999) A prospective, randomized study comparing the results of open discectomy with those of video-assisted arthroscopic microdiscectomy. J Bone Joint Surg Ser A 81(7):958–965

    CAS  Google Scholar 

  28. Kim MJ, Lee SH, Jung ES, Son BG, Choi ES, Shin JH, Sung JK, Chi YC (2007) Targeted percutaneous transforaminal endoscopic diskectomy in 295 patients: comparison with results of microscopic diskectomy. Surg Neurol 68(6):623–631

    Article  PubMed  Google Scholar 

  29. Krappel FA, Schmitz R, Bauer E, Harland U (2001) Open or endoscopic nucleotomy? Results of a prospective, controlled clinial trial with independent follow-up, MRI and special reference to cost-effectiveness. Orthopadische Prax 37(3):164–169

    Google Scholar 

  30. Lee DY, Shim CS, Ahn Y, Choi YG, Kim HJ, Lee SH (2009) Comparison of percutaneous endoscopic lumbar discectomy and open lumbar microdiscectomy for recurrent disc herniation. J Korean Neurosurg Soc 46(6):515–521

    Article  PubMed Central  PubMed  Google Scholar 

  31. Lee SH, Chung SE, Ahn Y, Kim TH, Park JY, Shin SW (2006) Comparative radiologic evaluation of percutaneous endoscopic lumbar discectomy and open microdiscectomy: a matched cohort analysis. Mt Sinai J Med 73(5):795–801

    PubMed  Google Scholar 

  32. Mayer HM, Brock M (1993) Percutaneous endoscopic discectomy: surgical technique and preliminary results compared to microsurgical discectomy. J Neurosurg 78(2):216–225

    Article  CAS  PubMed  Google Scholar 

  33. Ruetten S, Komp M, Merk H, Godolias G (2008) Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study. Spine 33(9):931–939

    Article  PubMed  Google Scholar 

  34. Ruetten S, Komp M, Merk H, Godolias G (2009) Recurrent lumbar disc herniation after conventional discectomy: a prospective, randomized study comparing full-endoscopic interlaminar and transforaminal versus microsurgical revision. J Spinal Disord Tech 22(2):122–129

    Article  PubMed  Google Scholar 

  35. Guyatt GH, Oxman AD, Kunz R, Brozeka J, Alonso-Coellof P, Rind D, Devereaux PJ, Montorih VA, Freyschussi B, Vist G, Jaeschke R, Williams JW, Muradh MH, Sinclair D, Falck-Ytterl Y, Meerpohlm J, Whittington C, Thorlunda K, Andrews J, Schunemann HJ (2011) GRADE guidelines 6. Rating the quality of evidence imprecision. J Clin Epidemiol 64:1283–1293

    Article  PubMed  Google Scholar 

  36. Nellensteijn J, Ostelo R, Bartels R, Peul W, Van Royen B, van Tulder M (2010) Transforaminal endoscopic surgery for symptomatic lumbar disc herniations: a systematic review of the literature. Eur Spine J 19(2):181–204

    Article  PubMed Central  PubMed  Google Scholar 

  37. Van Den Akker ME, Arts MP, van den Hout WB, Brand R, Koes BW, Peul W (2011) Tubular diskectomy vs conventional microdiskectomy for the treatment of lumbar disk-related sciatica: cost utility analysis alongside a double-blind randomized controlled trial. Neurosurgery 69(4):829–836

    Article  PubMed  Google Scholar 

  38. Lee DY, Lee S-H (2008) Learning curve for percutaneous endoscopic lumbar discectomy. Neurol Med Chir 48(9):383–389

    Article  Google Scholar 

  39. Gibson JNA, Cowie JG, Iprenburg M (2012) Transforaminal endoscopic spinal surgery: the future ‘gold standard’ for discectomy? A review. Surgeon 10:290–296

    Article  PubMed  Google Scholar 

  40. Jacobs WCH, Arts MP, van Tulder MW, Rubinstein SM, van Middelkoop M, Ostelo RW, Verhagen AP, Koes BW, Peul WC (2012) Surgical techniques for sciatica due to herniated disc, a systematic review. Eur Spine J 21:2232–2251

    Article  PubMed Central  PubMed  Google Scholar 

  41. Chatterjee S, Foy PM, Findlay GF (1995) Report of a controlled clinical trial comparing automated percutaneous lumbar discectomy and microdiscectomy in the treatment of contained lumbar disc herniation. Spine 20:734–738

    Article  CAS  PubMed  Google Scholar 

  42. Lemcke J, Al-Zain F, Mutze S, Meier U (2010) Minimally invasive spinal surgery using nucleoplasty and the dekompressor tool: a comparison of two methods in a one year follow-up. Minim Invasive Neurosurg 53(5–6):236–242

    Article  CAS  PubMed  Google Scholar 

  43. Maroon JC, Abla A (1985) Microdiscectomy versus chemonucleolysis. Neurosurgery 16:644–649

    Article  CAS  PubMed  Google Scholar 

  44. Tassi GP (2006) Comparison of results of 500 microdiscectomies and 500 percutaneous laser disc decompression procedures for lumbar disc herniation. Photomed Laser Surg 24(6):694–697

    Article  PubMed  Google Scholar 

  45. Furlan AD, Pennick V, Bombardier C, van Tulder M (2009) Updated method guidelines for systematic reviews in the cochrane back review group. Spine 34(18):1929–1941

    Article  PubMed  Google Scholar 

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Conflict of interest

Part of this study was funded by the Dutch College for Health Insurance (CVZ), RO has received research funding from AO Spine, Netherlands Organisation for Health Care Research (ZonMW), Netherlands Scientific College for Physiotherapy, WP has received research funding from ZonMW, Medtronic, Braun, Pardigm Spine, MvT has received research funding from ZonMW

Author information

Authors and Affiliations

  1. Department of Epidemiology and Biostatistics, VU University Medical Centre, The EMGO+ Institute for Health and Care Research, Vander Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands

    Steven J. Kamper, Raymond W. J. G. Ostelo & Maurits W. van Tulder

  2. The George Institute for Global Health, University of Sydney, Sydney, Australia

    Steven J. Kamper

  3. Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands

    Raymond W. J. G. Ostelo, Sidney M. Rubinstein & Maurits W. van Tulder

  4. Department of Orthopedic Surgery, VUmc, Amsterdam, The Netherlands

    Jorm M. Nellensteijn

  5. Department of Neurosurgery, LUMC, Leiden, The Netherlands

    Wilco C. Peul

  6. Department of Neurosurgery, Medical Centre Haaglanden, The Hague, The Netherlands

    Wilco C. Peul & Mark P. Arts

Authors
  1. Steven J. Kamper
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  2. Raymond W. J. G. Ostelo
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  3. Sidney M. Rubinstein
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  4. Jorm M. Nellensteijn
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  5. Wilco C. Peul
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  6. Mark P. Arts
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  7. Maurits W. van Tulder
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Corresponding author

Correspondence to Steven J. Kamper.

Appendix

Appendix

See Tables 2 3 4 5 6, 7 and Fig. 4.

Table 2 MEDLINE search strategy
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Table 3 Excluded studies
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Table 4 Risk of bias assessments
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Table 5 ILMI vs. MD GRADE evidence summary
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Table 6 TFMI vs. MD GRADE evidence summary
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Table 7 ILMI + TFMI vs. MD GRADE evidence summary
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Fig. 4
figure 4

Flow of studies

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Kamper, S.J., Ostelo, R.W.J.G., Rubinstein, S.M. et al. Minimally invasive surgery for lumbar disc herniation: a systematic review and meta-analysis. Eur Spine J 23, 1021–1043 (2014). https://doi.org/10.1007/s00586-013-3161-2

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  • DOI: https://doi.org/10.1007/s00586-013-3161-2

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