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This study compared the 1-year clinical outcomes and disc degeneration rates after transforaminal full-endoscopic lumbar discectomy (TF-FED), condoliase injection, open discectomy (OD), and microendoscopic discectomy (MED) for lumbar disc herniation (LDH). In total, 279 patients with LDH were divided into four treatment groups: TF-FED, OD, MED, and condoliase injection. Outcomes were evaluated on the basis of the complication rate, Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), visual analog scale (VAS) scores, and the modified MacNab criteria. Surgical and hospital costs were assessed. Disc degeneration and endplate bone marrow edema were evaluated using magnetic resonance images. The mean postoperative JOABPEQ, VAS, or modified MacNab scores among the four groups had no significant differences. Additionally, the nerve injury or reoperation rate among the TF-FED, OD, and MED groups had no significant difference. However, the reoperation rate with condoliase injection was high because of residual disc herniation. Surgical and hospital costs were lower with condoliase injection and higher with OD and MED than those with TF-FED. With TF-FED and condoliase injection, the Pfirrmann grade progressed, and the disc height was significantly smaller than that with OD and MED. Endplate bone marrow edema was more common with condoliase injection and TF-FED. All groups had good outcomes. TF-FED and condoliase injection may reduce the burden of surgery because they can be performed under local anesthesia with little blood loss and low medical costs but tend to be associated with disc degeneration and endplate bone marrow edema. A randomized controlled study with a larger sample is needed.

Transforaminal full-endoscopic lumbar discectomy (TELD) can be performed under local anesthesia. However, there have been no reports on risk factors for a change in vital signs or the need for additional medications to maintain adequate analgesia during this procedure. The purpose of this study was to identify risk factors for additional intravenous medication during TELD under local anesthesia. The following factors were retrospectively evaluated in 113 consecutive patients who underwent TELD under local anesthesia at our institution: demographic characteristics, radiological features at the intervertebral disc level, distance between the superior articular process and the exiting nerve root, height of the intervertebral disc, height of the bulging disc, height of the intervertebral foramen, and distance from the insertion site to the spinous process on magnetic resonance imaging (MRI) and computed tomography (CT) scans of the lumbar spine. Logistic regression analysis was performed to determine factors associated with the need for additional drugs. In all, 23 cases (20.4%) required additional intraoperative medications because of hypertension, hypotension, bradycardia, or pain. Logistic regression analysis revealed that age (partial regression coefficient 0.05, p = 0.02) and bulging disc height (partial regression coefficient -0.7, p = 0.003) influenced the need for additional drugs. There were significant associations of need for additional intravenous medication with older age (>62 years) and a smaller bulging disc height (<8.2 mm). Patients with these factors require close monitoring for changes in vital signs or increasing pain when performing TELD under local anesthesia and may need additional intravenous medication.

Transforaminal full-endoscopic spine (TF-FES) surgery is minimally invasive and can be performed under local anesthesia. Thus, it is expected that the patient can return to work (RTW) quickly. However, information in the literature regarding this is sparse. The purpose of this study is to review the timing of RTW after TF-FES surgery. This study involved 50 patients (14 women, 36 men; mean age 44.5 years, age range: 20-65 years) who underwent TF-FES surgery between January 2016 and April 2018. All the patients were active workers. Occupations varied widely (e.g., physician, nurse, helper, clerk, construction worker, chef, and schoolteacher). There were no surgery-related complications. Median time to RTW was 21 days. More than half of the patients could RTW within 21 days. In all, 12 cases (24%) could have RTW within 7 days. Occupations of 12 patients who achieved RTW within 7 days included physician, company owner, and restaurant owner, with 11 in the Light work, 1 was in the Medium work, and none in the Heavy work. All 12 had a quick RTW because their work was Light and they could not take prolonged sick leave. Prompt RTW is possible with TF-FES surgery. The biggest merit of TF-FES surgery is minimal invasiveness to the muscles of the back. Also, it can be performed under local anesthesia. Our findings reveal quicker RTW after surgery, depending on occupational type.

For full-endoscopic lumbar discectomy, operating costs are also important because expensive equipment are necessary. We surveyed the operating costs of surgical equipment necessary for full-endoscopic surgery together with surgical procedure reimbursement fees. A total of 295 cases of full-endoscopic surgery via a transforaminal approach were retrospectively analyzed. We calculated the frequency of damage and the unit purchase price of devices such as endoscopes, and surgical instruments such as grasping forceps for nucleotomy, high-speed drill bar, and bipolar forceps, and examined the operating costs in Japanese yen against the procedure fee per case. Endoscope breakage occurred seven times, and a payment of ¥760,000 was necessary for trade-in and purchase of a new endoscope. The total breakage number of grasping forceps was 58, and the purchase price per unit was ¥116,000. Therefore, a total of ¥12,020,000 was required for the 295 cases, and the calculated operating cost that accompanies equipment breakage was ¥40,000 per case. In addition, about ¥118,000 was required for disposable bipolar forceps and high-speed drill bar to be used intraoperatively for each case. Thus, for one case it is calculated that total ¥158,000 is utilized for equipment from the surgical reimbursement fee per case specified by the Japanese Ministry of Health being ¥303,900. Minimally invasive procedures provide great benefit to patients; however, the eventual contribution to hospital profits is small and may not be sufficient. To resolve this issue, the cost of surgical equipment should be lowered and/or the surgical reimbursement fee of the full-endoscopic surgery should be raised.

The purpose of this study was to assess the usefulness of radiofrequency thermal annuloplasty (TA) using percutaneous endoscopic discectomy/TA (PED/TA) in elite athletes with discogenic low back pain. Twelve patients (11 men, 1 woman; mean age 27.9 years) underwent PED/TA under local anesthesia. Clinical data for these patients (17 affected intervertebral discs), including type of sport played, average duration of low back pain, disc level affected, presence or absence of a high signal intensity zone on magnetic resonance imaging, and whether the patient returned to playing competitive sport, were retrospectively reviewed. The most common sport played by the patient was baseball (n = 8), followed by cycling (n = 2), tennis (n = 1), and hammer throw (n = 1). The average duration of low back pain was 24.3 months. The intervertebral disc levels affected were L4/5 (n = 11) and L5/S1 (n = 6). A high signal intensity zone was detected in nine discs. Although two patients required additional surgery, all patients were able to return to their original competitive level of play. Duration for the return to play was 2.8 months after surgery except the two revision cases. PED/TA for discogenic pain enables an early return to competitive sports, and so is particularly useful for elite athletes.

Lumbar spondylolysis usually occurs as a stress fracture in the pars interarticularis of the vertebra. It is a prevalent sports-related disorder and a common cause of low back pain. We encountered five athletes (4 males, 1 female) with severe low back pain. Mean age was 14.5 years. All five patients were found to have bilateral pars fracture. In all cases, staging based on the findings from computed tomography scan of the right and left pars fracture was different. On short tau inversion recovery magnetic resonance imaging (STIR-MRI) of the comparatively newer more recently injured side, high signal intensity changes were obvious and dominant at the intra- and extraosseous area, which would indicate tissue edema and/or bleeding. Furthermore, the imaging findings corresponded to the side of the low back pain. In conclusion, STIR-MRI can effectively distinguish between painful pars fracture and painless pars fracture.