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Transforaminal endoscopic lumbar discectomy using a 45° puncture angle and foraminotomy versus traditional THESYS for L5/S1 lumbar disc herniation: a prospective randomized controlled trial

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Abstract

Purpose

Prospective comparison of the efficacy and safety of transforaminal endoscopic lumbar discectomy (TELD) with a 45° puncture angle versus traditional Thomas Hoogland endoscopy spine systems (THESYS) for the surgical treatment of L5/S1 lumbar disc herniation (LDH).

Methods

Consecutive patients with L5/S1 LDH who underwent TELD were randomized (1:1) assigned to the 45° TELD group and the THESYS group. Clinical outcomes were assessed at pre-operation, 1-day and 3/6-months post-operation till final follow-up. Surgical-related parameters, visual analogue scale (VAS) score, oswestry disability index (ODI), and modified MacNab criteria, and surgical complications were recorded and analysed.

Results

All patients were followed up for at least 24 months. Compared to the THESYS group, the 45° TELD group had a shorter operative time (P < 0.001) and intraoperative radiation time (P < 0.001) and a smaller VAS score for back pain (P < 0.001) and leg pain intraoperatively (P < 0.001). The VAS and ODI in the 45° TELD group were significantly better than those in the THESYS group within 3 months postoperatively. However, from 3 months on, both groups showed comparable VAS and ODI. There was no significant difference between the two groups of modified MacNab criteria. There were two cases of residual disc and two cases of recurrence that required reoperation in the THESYS group.

Conclusion

For L5/S1 LDH, the 45° TELD technique was superior to traditional THESYS in terms of surgery-related parameters and faster improvement of VAS and ODI, with a lower complication rate.

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References

  1. Kim M, Lee S, Kim H-S, Park S, Shim S-Y, Lim D-J (2018) A Comparison of percutaneous endoscopic lumbar discectomy and open lumbar microdiscectomy for lumbar disc herniation in the korean: a meta-analysis. Biomed Res Int 2018:9073460. https://doi.org/10.1155/2018/9073460

    Article  PubMed  PubMed Central  Google Scholar 

  2. Li Z, Zhang C, Chen W, Li S, Yu B, Zhao H, Shen J, Zhang J, Wang Y, Yu K (2020) Percutaneous endoscopic transforaminal discectomy versus conventional open lumbar discectomy for upper lumbar disc herniation: a comparative cohort study. Biomed Res Int 2020:1852070. https://doi.org/10.1155/2020/1852070

    Article  PubMed  PubMed Central  Google Scholar 

  3. Gadjradj PS, Rubinstein SM, Peul WC, Depauw PR, Vleggeert-Lankamp CL, Seiger A, van Susante JL, de Boer MR, van Tulder MW, Harhangi BS (2022) Full endoscopic versus open discectomy for sciatica: randomised controlled non-inferiority trial. BMJ (Clin Res ed) 376:e065846. https://doi.org/10.1136/bmj-2021-065846

    Article  Google Scholar 

  4. Gadjradj PS, Broulikova HM, van Dongen JM, Rubinstein SM, Depauw PR, Vleggeert C, Seiger A, Peul WC, van Susante JL, van Tulder MW, Harhangi BS (2022) Cost-effectiveness of full endoscopic versus open discectomy for sciatica. Br J Sports Med. https://doi.org/10.1136/bjsports-2021-104808

    Article  PubMed  Google Scholar 

  5. Chen J, Jing X, Li C, Jiang Y, Cheng S, Ma J (2018) Percutaneous endoscopic lumbar discectomy for L5S1 lumbar disc herniation using a transforaminal approach versus an interlaminar approach: a systematic review and meta-analysis. World Neurosurg. https://doi.org/10.1016/j.wneu.2018.05.075

    Article  PubMed  PubMed Central  Google Scholar 

  6. Jiang X, Zhou X, Xu N (2018) Clinical effects of transforaminal and interlaminar percutaneous endoscopic discectomy for lumbar disc herniation: a retrospective study. Medicine (Baltimore) 97:e13417. https://doi.org/10.1097/MD.0000000000013417

    Article  PubMed  Google Scholar 

  7. Gao A, Yang H, Zhu L, Hu Z, Lu B, Jin Q, Wang Y, Gu X (2021) Comparison of interlaminar and transforaminal approaches for treatment of L/S disc herniation by percutaneous endoscopic discectomy. Orthop Surg 13:63–70. https://doi.org/10.1111/os.12831

    Article  PubMed  Google Scholar 

  8. Nie H, Zeng J, Song Y, Chen G, Wang X, Li Z, Jiang H, Kong Q (2016) Percutaneous endoscopic lumbar discectomy for L5-S1 disc herniation via an interlaminar approach versus a transforaminal approach: a prospective randomized controlled study with 2-year follow up. Spine 41(Suppl 19):B30–B37

    Article  PubMed  Google Scholar 

  9. Guan Y, Huang T, An G, Wan R, Wei T, Shi X, Liu J, Liu K, Wang Y (2019) Percutaneous endoscopic interlaminar lumbar discectomy with local anesthesia for L5-S1 disc herniation: a feasibility study. Pain Physician 22:E649–E654

    PubMed  Google Scholar 

  10. Chen P, Hu Y, Li Z (2019) Percutaneous endoscopic transforaminal discectomy precedes interlaminar discectomy in the efficacy and safety for lumbar disc herniation. Biosci Rep. https://doi.org/10.1042/BSR20181866

  11. Chen K-T, Wei S-T, Tseng C, Ou S-W, Sun L-W, Chen C-M (2020) Transforaminal endoscopic lumbar discectomy for L5-S1 disc herniation with high iliac crest: technical note and preliminary series. Neurospine 17:S81–S87. https://doi.org/10.14245/ns.2040166.060

    Article  ADS  PubMed  PubMed Central  Google Scholar 

  12. Hoogland T, Schubert M, Miklitz B, Ramirez A (2006) Transforaminal posterolateral endoscopic discectomy with or without the combination of a low-dose chymopapain: a prospective randomized study in 280 consecutive cases. Spine 31:E890–E897. https://doi.org/10.1097/01.brs.0000245955.22358.3a

    Article  PubMed  Google Scholar 

  13. Gu Y-T, Cui Z, Shao H-W, Ye Y, Gu A-Q (2017) Percutaneous transforaminal endoscopic surgery (PTES) for symptomatic lumbar disc herniation: a surgical technique, outcome, and complications in 209 consecutive cases. J Orthop Surg Res 12:25. https://doi.org/10.1186/s13018-017-0524-0

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Mirkovic SR, Schwartz DG, Glazier KD (1995) Anatomic considerations in lumbar posterolateral percutaneous procedures. Spine 20:1965–1971

    Article  CAS  PubMed  Google Scholar 

  15. Reulen HJ, Müller A, Ebeling U (1996) Microsurgical anatomy of the lateral approach to extraforaminal lumbar disc herniations. Neurosurgery 39:345–351

    Article  CAS  PubMed  Google Scholar 

  16. Choi G, Lee S-H, Lokhande P, Kong BJ, Shim CS, Jung B, Kim J-S (2008) Percutaneous endoscopic approach for highly migrated intracanal disc herniations by foraminoplastic technique using rigid working channel endoscope. Spine 33:E508–E515. https://doi.org/10.1097/BRS.0b013e31817bfa1a

    Article  PubMed  Google Scholar 

  17. Chen Z, Wang X, Cui X, Zhang G, Xu J, Lian X (2022) Transforaminal versus interlaminar approach of full-endoscopic lumbar discectomy under local anesthesia for L5/S1 disc herniation: a randomized controlled trial. Pain Physician 25:E1191–E1198

    PubMed  Google Scholar 

  18. Faul F, Erdfelder E, Lang A-G, Buchner A (2007) G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 39:175–191

    Article  PubMed  Google Scholar 

  19. Faul F, Erdfelder E, Buchner A, Lang A-G (2009) Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods 41:1149–1160. https://doi.org/10.3758/BRM.41.4.1149

    Article  PubMed  Google Scholar 

  20. Chen Z, Zhang L, Dong J, Xie P, Liu B, Wang Q, Chen R, Feng F, Yang B, Shu T, Li S, Yang Y, He L, Pang M, Rong L (2018) Percutaneous transforaminal endoscopic discectomy compared with microendoscopic discectomy for lumbar disc herniation: 1-year results of an ongoing randomized controlled trial. J Neurosurg Spine SPI 28:300–310. https://doi.org/10.3171/2017.7.Spine161434

    Article  Google Scholar 

  21. Shi C, Kong W, Liao W, Lu Y, Fu Y, Wen H, Du Q, Wu F (2018) The Early clinical outcomes of a percutaneous full-endoscopic interlaminar approach via a surrounding nerve root discectomy operative route for the treatment of ventral-type lumbar disc herniation. Biomed Res Int 2018:9157089. https://doi.org/10.1155/2018/9157089

    Article  PubMed  PubMed Central  Google Scholar 

  22. Ahn Y (2019) Endoscopic spine discectomy: indications and outcomes. Int Orthop 43:909–916. https://doi.org/10.1007/s00264-018-04283-w

    Article  PubMed  Google Scholar 

  23. Chen K-T, Tseng C, Sun L-W, Chang K-S, Chen C-M (2021) Technical considerations of interlaminar approach for lumbar disc herniation. World Neurosurg 145:612–620. https://doi.org/10.1016/j.wneu.2020.06.211

    Article  PubMed  Google Scholar 

  24. Feng W-L, Yang J-S, Wei D, Gong H-L, Xi Y, Lv H-Q, Wang X-G, Xia B, Wei J-M (2020) Gradient local anesthesia for percutaneous endoscopic interlaminar discectomy at the L5/S1 level: a feasibility study. J Orthop Surg Res 15:413. https://doi.org/10.1186/s13018-020-01939-5

    Article  PubMed  PubMed Central  Google Scholar 

  25. Zhang L, Chang T, Xu Y, Jing Q, Zhao X, Li C (2020) Epidural anesthesia with low concentration ropivacaine and sufentanil for percutaneous transforaminal endoscopic discectomy: a randomized controlled trial. Front Med (Lausanne) 7:362. https://doi.org/10.3389/fmed.2020.00362

    Article  ADS  PubMed  Google Scholar 

  26. Chen Z, Zhang L, Dong J, Xie P, Liu B, Wang Q, Chen R, Shu T, Li S, Feng F, Yang B, He L, Yang Y, Liu Z, Pang M, Rong L (2020) Percutaneous transforaminal endoscopic discectomy versus microendoscopic discectomy for lumbar disc herniation: two-year results of a randomized controlled trial. Spine (Phila Pa 1976) 45:493–503. https://doi.org/10.1097/BRS.0000000000003314

    Article  PubMed  Google Scholar 

  27. Choi K-C, Lee J-H, Kim J-S, Sabal LA, Lee S, Kim H, Lee S-H (2015) Unsuccessful percutaneous endoscopic lumbar discectomy: a single-center experience of 10,228 cases. Neurosurgery. https://doi.org/10.1227/NEU.0000000000000628

    Article  PubMed  Google Scholar 

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Funding

This work was supported by grants from Clinical Trial Project of Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (ynhg202003) and General Program of Shanghai Municipal Health Commission (202040189).

Author information

Author notes

  1. Yuxuan Qian, Zhiheng Chen and Guowang Zhang have contributed equally to this work.

Authors and Affiliations

  1. Department of Orthopedics, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China

    Yuxuan Qian, Zhiheng Chen, Guowang Zhang, Xin Wang, Ji Liu, Jianguang Xu & Xiaofeng Lian

  2. Department of Orthopedics, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, People’s Republic of China

    Aofei Yang

Authors
  1. Yuxuan Qian
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  2. Zhiheng Chen
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  3. Guowang Zhang
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  4. Xin Wang
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  5. Ji Liu
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  6. Aofei Yang
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  7. Jianguang Xu
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  8. Xiaofeng Lian
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Contributions

XL and JX conceived and supervised the study. YQ and ZC wrote the original draft of the manuscript. GZ revised the manuscript. XW generated the random allocation sequence. JL assessed for patients’ eligibility and enrolled patients. XL performed the surgical procedure. AY assessed outcomes.

Corresponding authors

Correspondence to Jianguang Xu or Xiaofeng Lian.

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Qian, Y., Chen, Z., Zhang, G. et al. Transforaminal endoscopic lumbar discectomy using a 45° puncture angle and foraminotomy versus traditional THESYS for L5/S1 lumbar disc herniation: a prospective randomized controlled trial. Eur Spine J 33, 453–462 (2024). https://doi.org/10.1007/s00586-023-08117-1

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  • DOI: https://doi.org/10.1007/s00586-023-08117-1

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