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Local anesthesia is feasible for both transforaminal and interlaminar approaches in percutaneous endoscopic lumbar discectomy (PELD). However, the optimal approach for PELD has not yet been established at the L5/S1 segment under local anesthesia with 1% lidocaine.In this study, we compared the transforaminal approach with the interlaminar approach of PELD under local anesthesia for L5/S1 disc herniation (DH).This was a prospective randomized clinical trial.From January 2019 to March 2020, 91 consecutive patients with L5/S1 DH who planned to undergo PELD in our unit were randomized to the transforaminal endoscopic lumbar discectomy (TELD, n = 46) or interlaminar endoscopic lumbar discectomy (IELD, n = 45). Both procedures were performed under local anesthesia with 1% lidocaine. The clinical outcomes were assessed as the Visual Analog Scale (VAS) score, Oswestry Disability Index (ODI) score, and modified MacNab criteria. Patient satisfaction surveys and surgical complications were also recorded and analyzed.Compared to the IELD group, the TELD group had a shorter operative time and postoperative bed rest time (P0.001) but a longer radiation time (P0.001) and lower VAS scores for intraoperative back pain (P0.001) and leg pain (P0.001). At the postoperative follow-up, there were no significant differences between the 2 groups in the VAS scores, ODI scores, or modified MacNab criteria. The surveys showed a significantly higher satisfaction rate in the TELD group than in the IELD group (P = 0.014). Six patients in the IELD group (13.3%) needed extra intravenous injections of sufentanil because of intense pain during the procedure. In the IELD group, there were 2 cases of neuropathic pain after surgery.Due to the study was included in a single spine center with a relatively small population and its relatively short-term follow-up, the study is not generalizable.Both TELD and IELD can provide good clinical outcomes for L5/S1 DH under local anesthesia with 1% lidocaine. TELD was superior to IELD in terms of surgical-related experience and complications.

Transforaminal epidural steroid injections (TFESI) are widely used to alleviate lumbosacral radicular pain. Knowledge of the therapeutic outcomes of TFESI allows clinicians to elucidate therapeutic plans for managing lumbosacral radicular pain. Deep learning (DL) can outperform traditional machine learning techniques and learn from unstructured and perceptual data. A convolutional neural network (CNN) is a representative DL model.We developed and investigated the accuracy of a CNN model for predicting therapeutic outcomes after TFESI for controlling chronic lumbosacral radicular pain using T2-weighted sagittal lumbar spine magnetic resonance (MR) images as input data.Imaging study using DL.At the spine center of a university hospital.We collected whole T2-weighted sagittal lumbar spine MR images from 503 patients with chronic lumbosacral radicular pain due to a herniated lumbar disc (HLD) and spinal stenosis. A "good outcome" was defined as a= 50% reduction in the numeric rating scale (NRS-11) score at 2 months after TFESI vs the pretreatment NRS-11 score. A "poor outcome" was defined as a50% decrease in the NRS-11 score at 2 months after TFESI vs pretreatment.In the prediction of therapeutic outcomes after TFESI on the validation dataset, the area under the curve was 0.827.Our study was limited in that we used a small amount of lumbar spine MR imaging data to train the CNN model.We demonstrated that a CNN model trained, using whole lumbar spine sagittal T2-weighted MR images, could help determine outcomes after TFESI in patients with chronic lumbosacral radicular pain due to an HLD or spinal stenosis.

Lumbar disc herniation (LDH) is the main cause of low back pain and/or radiculopathy. Currently, epidural intervention is a widely used and effective conservative treatment method for managing low back and radicular pain caused by LDH.To explore the effectiveness of different epidural injection approaches in adult patients with lumbosacral radicular pain.Systematic review and network meta-analysis (NMA).An electronic literature search was performed in the Pubmed, Embase, Cochrane Library, and Web of Science databases. Two authors independently performed data extraction and quality assessment. A Bayesian random effects model was conducted to incorporate the estimates of direct and indirect treatment comparisons and rank the interventions in order. Effect estimates from Bayesian NMA were presented as mean difference (MD) with 95% credible intervals (CrI).This NMA assessed caudal (C), interlaminar (IL), transforaminal (TF) and parasagittal interlaminar (PIL) epidural injection approaches for lumbosacral radicular pain from 7 trials. A statistically significant treatment difference for pain relief was reported for midline interlaminar (MIL) vs PIL (MD, 1.16; 95%CrI, 0.31-2.06), MIL vs TF (MD, 1.12; 95%CrI, 0.51-1.85), C vs TF (MD, 1.07; 95%CrI, 0.01-2.18) in short-term follow-up and MIL vs TF (MD, 1.8; 95% CrI, 0.3-3.48) in intermediate-term follow-up. For functional improvement, a statistically significant difference was observed with MIL vs PIL (MD, 9.9; 95% CrI, 0.64-19.94) and MIL vs TF (MD, 1.08; 95% CrI, 1.08-17.08) in short-term follow-up. Moreover, the PIL approach and TF appeoach were ranked in the top 2 for pain relief and functional improvement, both in short-term and intermediate-term follow-up.1) The number of studies included was small; 2) some treatments lacked direct comparisons; 3) only scores from the visual analog scale for pain and the Oswestry Disability Index were included in the result; 4) important outcomes, such as complications, were not included.In short-term and intermediate-term follow-up, the PIL approach has the highest probability for pain relief and functional improvement.

Postoperative upper-limb palsy (ULP) is a serious complication after cervical spine surgery. ULP after posterior percutaneous endoscopic cervical foraminotomy and discectomy (PPCED) has not yet been reported.To introduce cases of postoperative ULP after PPCED and associated risk factors.A single-center, retrospective, observational study.Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China.From January 2016 through January 2022, PPCED involving a total of 663 segments was performed in 610 patients with radiculopathy who were diagnosed with cervical radiculopathy or mixed cervical spondylosis caused by foraminal stenosis or posterolateral disc herniation.PPCED was successfully completed in 610 patients, 6 of whom (0.98%) developed ULP. Two patients were diagnosed with double-segment cervical nerve root canal stenosis (C4/5/6, C5/6/7) and 2 with migrated cervical disc soft herniation (a magnetic resonance image of one showed a migrated disc herniation downward from C4/5 in the sagittal plane; another showed this upward from C5/6); one patient was diagnosed with C5/6 intervertebral foraminal stenosis, and one had simple C4/5 lateral disc herniation. Postoperative ULP rates for C4/5 (2/30, 6.67%) and C5/6 (2/177, 1.13%) were much higher than those for the other levels. Anatomically, the width of the intervertebral foramen on computed tomography was 2.3 ± 1.12 mm in ULP cases, which was significantly lower than that in non-ULP cases (3.4 ± 1.83, P0.05). This suggests that preoperative foramen width correlates highly negatively with postoperative ULP incidence.This was a single-center, retrospective, nonrandomized study with a low level of evidence.PPCED is a good treatment for cervical radiculopathy. The rate of postoperative ULP after PPCED is much lower than that after posterior cervical foraminotomy. Perturbation to the C5 (or C6) nerve root, thermal injury due to burr use or the radiofrequency applied, and marked foraminal stenosis are possible relevant factors associated with postoperative ULP.

Recurrent LDH (rLDH) is one of the most common causes of unsatisfactory outcomes after discectomy, which usually needs secondary surgery and leads to physical and psychological suffering for patients and substantial costs for society.This study was conducted to analyze the risk factors of early rLDH (lt;= 6 months) and to reduce the incidence of early rLDH.A clinical retrospective study.A total of 1,228 patients received percutaneous endoscopic lumbar discectomy surgery from January 2013 through December 2016; there was a minimum 5-year follow-up. Seventy-seven of them (6.27%) developed recurrences and were included in this study. According to the differences in recurrent time, patients were divided into 2 groups (lt;= 6 months andgt; 6 months). Clinical and radiological parameters were retrospectively collected through chart review and preoperative imaging. All related risk factors were collected and analyzed relative to the time of recurrent herniation.Patients with rLDH atlt;= 6 months andgt; 6 months were 49 and 28, respectively. Recurrence most often occurred within 6 months postoperatively, which was 63.6% of the total patients with rLDH. Of those risk factors, Modic changes, disc height index (DHI), and facet orientation (FO) showed significant statistical differences P = 0.003, P = 0.036, and P = 0.007, respectively). A logistic regression analysis was performed and showed there was an independent significant relationship between Modic changes (P = 0.042) and FO (P = 0.005) and early rLDH.First, this was a retrospective nonrandomized study, and the number of patients with rLDH included in this study was relatively small. Second, limited risk factors were assessed in this study, and some relevant risk factors that were identified as significant independent predictors in other studies were not included in this study, such as canal diameter, annular defect size, migrated disc, and foraminoplasty. Third, this study compared the clinical and radiological parameters of patients with rLDH at different times, and one case-control study is needed for further study, especially in terms of standardized sampling and data classification.This study demonstrated that the recurrence rate of LDH at 5-year follow-up was 6.27% and there was a significant statistical relationship between FO, DHI, and Modic changes and early rLDH. Surgeons should take FO angles, DHI, and Modic change into consideration before surgery to achieve a satisfactory postoperative outcome and a relatively lower early recurrence rate. More patients and further investigation should be taken to assess the risk factors for early rLDH.

For patients with lumbosacral contiguous double-level disc herniation, there has been no consensus on which level(s) should be treated. Selective nerve root block (SNRB) can identify the pain-generating nerve root; however, its diagnostic accuracy remains controversial due to potential spread of the injectate. Sequential SNRB from S1 to L5 may improve the diagnostic specificity.To examine the clinical and radiographic outcomes of percutaneous endoscopic lumbar discectomy (PELD) assisted with sequential SNRB from S1 to L5 in patients who had lumbosacral contiguous double-level disc herniation.A retrospective design was used.This study was conducted in a university-affiliated tertiary hospital in Shanghai, China.Fifty-eight consecutive patients with lumbosacral contiguous double-level disc herniation were included (January 2018 to January 2021). Sequential SNRB from S1 to L5 was performed to identify the symptomatic level(s), followed by PELD based on the results of sequential SNRB. Clinical outcomes were assessed by the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and modified Macnab criteria. Pre- and post-operation radiologic and clinical parameters were evaluated. Demographics were retrieved from medical records.Patients were followed-up with an average duration of 18.6 months. Among the 58 patients, 21 received surgical treatment at L4/L5 level, 25 at L5/S1 level, and 12 at both levels based on the results of sequential SNRB from S1 to L5. Compared with preoperative values, mean VAS scores for leg and back pain, as well as the ODI score, improved significantly after the surgery. There were no significant differences in the clinical outcomes between patients receiving surgical treatment at L4/L5, L5/S1, or both levels. According to the Macnab criteria, 49 patients (84.5%) had excellent or good results.This study used a retrospective design with relatively small sample size and medium follow-up duration.Sequential SNRB from S1 to L5 was an effective approach to guide PELD treatment for patients with lumbosacral contiguous double-level disc herniation. Health care providers may consider using this approach to facilitate future clinical practice.

Percutaneous cervical nucleoplasty (PCN) is a minimally invasive technique used for the treatment of cervical disc herniation. However, if the lesion is located at the neural foramen, complete access and effective neural decompression are often challenging because of the special anatomical condition of the uncovertebral joint, osteophyte, and facet joint of the cervical foraminal space.To investigate the effect of PCN on radiculopathy caused by foraminal cervical disc herniation (FCDH).Retrospective case series.Single-center tertiary hospital.This study included 44 patients with radiculopathy caused by FCDH who were treated with PCN. Visual analog scale (VAS) scores, preoperative, 1 week, and 3 months postoperatively, and at the last follow-up, as well as the Macnab criteria, were used to evaluate clinical outcomes. A paired t-test was used to compare the preoperative and follow-up VAS scores. The percentage of patients with VAS scoreslt;= 3 at each follow-up time point was also investigated. Statistical significance was set at Plt; 0.05.Twenty-seven men (62.4%) and 17 women (38.6%) were enrolled in this study. The mean age was 54.5 years (range 31-81). The average follow-up period after the operation was 15.4 months (range 3.7-30.8). The mean preoperative VAS was 7.50 ± 1.21. The VAS scores at 1 week, 3 months, and the last follow-up were 4.36 ± 2.46, 3.20 ± 2.58, and 2.91 ± 2.74, respectively, showing a significant improvement in pain compared to before the operation (Plt; 0.001 for all). The number of patients (percentage) with a VAS score oflt;= 3 was 20 (45.5%), 28 (63.6%), and 31 (70.5%) of 44 patients at 1 week, 3 months, and the last follow-up, respectively. The number of patients (percentage) with excellent, good, fair, or poor satisfaction according to the Macnab criteria was 17 (38.6%), 9 (20.5%), 8 (18.2%), and 10 (22.7%) of 44, respectively. No patients experienced postoperative complications.This study was retrospective and included a small number of patients from a single center.Although PCN for radiculopathy caused by FCDH is thought to have limitations because of the surrounding bony structure, the clinical outcome seemed favorable. If PCN is not contraindicated, it may be a viable treatment option for CR due to FCDH.

Central sensitization (CS) is a hyperexcitability that is manifested by the increased response of the central nervous system to sensory stimuli. It has been shown that the presence of CS may have a negative effect on the clinical picture in some musculoskeletal diseases and also have a negative effect on spinal procedures.To investigate the effect of CS on interlaminar epidural steroid injection (ILESI) treatment outcomes in patients with cervical disc herniation (CDH).An observational study.A university hospital pain management center.Patients, who underwent ILESI between 2020-2021 due to CDH, were included in the study. The Numeric Rating Scale (NRS-11), Neck Pain and Disability Scale (NPDS), Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS), and Short Form-12 (SF-12) were used for evaluation of patients. Patients were assessed before the procedure, at the first hour, and 3 months after the procedure. The presence of CS was investigated by the Central Sensitization Inventory (CSI).A total of 51 patients were included in the study. Twenty-three of the patients had CS, as assessed by the CSI. Although, patients who underwent ESI, had significantly lower NRS-11, S-LANSS, and NPDS scores, and higher SF-12 scores at all follow-up points. The first and third months, NRS-11, S-LANSS, and NPDS were significantly higher, and SF-12 scores were lower in the CS group compared to patients without CS.The short follow-up period and relatively low number of patients can be considered as a limitation. The fact that CS is not evaluated with a more objective method, such as Quantitative Sensory Testing (QST), can be considered as another limitation. Since most clinicians use CSI, so from a "real world" perspective the lack of QST may be observed as a strength of the study. The third limitation is that we did not evaluate the patients' pre- and posttreatment analgesic consumption. Finally, we did not include patients with a history of psychiatric illness, but not evaluating the current psychiatric conditions of the patients could be considered a limitation. Nevertheless, the main strengths of this study are its prospective design and, to our knowledge, it is the first study to explore the effects of CS on cervical ESI treatment.The presence of CS has a negative effect on pain scores, disability, and quality of life in patients undergoing cervical ESI due to CDH.

Symptomatic herniated intervertebral discs are debilitating. However, surgical management poses a significant challenge for endoscopic spine surgeons, especially in high-grade migrated lesions.This study aimed to assess the surgical and clinical outcomes after applying a computed tomography navigated percutaneous endoscopic lumbar discectomy.The data of patients with high-grade lumbar disc migration who underwent percutaneous endoscopic lumbar discectomy at our spine center were retrospectively collected and analyzed from November 2017 to May 2019. The patients were divided into 2 groups based on different workflows, with group O who underwent percutaneous endoscopic lumbar discectomy with computed-tomography navigation (O-arm), and group C who underwent conventional fluoroscopic guidance (C-arm).Twenty-one (n = 21) patients were enrolled with data fully documented. There were 9 patients in group O (n = 9) and 12 patients in group C (n = 12).An intraoperative 3-dimensional image was obtained using the O-arm device (O-arm®, Medtronic, Inc., Louisville, CO, United States) after patient positioning in group O, and enable multiplanar visualization during exploring the entry point, trajectory, orientation, and finally discectomy. In group C, conventional imaging scanner intensifier (C-arm) was used during the procedure.The operative time (99.4 ± 40.7 vs 86.9 ± 47.9 minutes, P = .129), blood loss (11.1 ± 15.7 vs 6.7 ± 8.2 mL, P = .602), and hospital stay (2.9 ± 0.3 vs 2.8 ± 0.6 days, P = .552) were similar between the 2 groups. However, group O showed more reduction in the pain and faster functional recovery immediately after the surgery (Visual Analog Score [VAS]: -9 vs -6.7, P =.277; Oswestry Disability Index [ODI]: -53.2% vs -29.1%, P = 0.006) and during the one-year follow-up (VAS: -8.1 vs -7.3, P =.604; ODI: -56.7% vs -40.1%, P = .053) compared with group C.The retrospective nature of the study design, the small population size, and the shorter period of follow-up required further study.Computed tomography-navigated percutaneous endoscopic surgery is safe and effective for lumbar disc herniation with high-grade migration, and enhance early functional recovery even compared with conventional fluoroscopic guidance.

Background: Sacroiliac joint (SIJ) abnormality is a potential source of low back pain (LBP), therefore numerous patients receive various treatments because of the degenerative changes of SIJ. However, the outcome is unfavorable for patients because these morphologic alterations are common but not the origins of LBP. Previous studies revealed lumbar fusion and transitional vertebra increased the prevalence of degeneration of SIJ. Lumbar disc herniation (LDH) is one of the most common lumbar diseases, but there is no study regarding the relationship between LDH and SIJ degradation. Objectives: The aim of this study was to investigate the severity of SIJ degeneration in patients with LBP with LDH. The relationship between degenerative changes of SIJ and LDH was also assessed. Study Design: Retrospective observational study. Setting: This study was conducted in 2 medical centers located in southeast and midwest China, respectively. Methods: Lumbar and pelvic computed tomography (CT) scans of patients with LDH (LDH group) from January 2016 to May 2020 were reviewed using a picture archiving and communication system. The control group was age, gender, and body mass index–matched patients with LBP without LDH. Patients underwent whole abdomen and pelvic CT examinations due to non-musculoskeletal disorders. Scores of SIJ degeneration were compared between patients with LDH and the control group. Differences in SIJ degeneration among patients with LDH with diverse characteristics, symptoms, and complications were also evaluated. Univariate and multivariate linear mixed model (LMM) was chosen to identify the factors associated with SIJ degeneration. Results: CT examinations of 782 patients with LDH were assessed, whereas 223 patients were in the control group. The SIJ degeneration score of the LDH group and control group were 6.00 (5.00) and 3.00 (4.00) (P < 0.05). Age and whether patients suffered from LDH were included in the LMM, which involved all reviewed patients (P < 0.05). Regarding the characteristics of LDH, the patients with more herniated discs had more severe SIJ degeneration. The score of SIJ degradation in patients with upper LDH was significantly higher than the other patients with LDH (12.00 [4.00] vs. 6.00 [4.00]; P < 0.05). Similarly, more significant SIJ degeneration was observed in patients with LDH who had secondary lumbar spinal stenosis (10.00 [4.00] vs. 5.00 [4.00]; P < 0.05). The scores of SIJ degradation were significantly greater in patients with LDH with sciatica, numbness, weakness, and/or cauda equina syndrome. Age and LDH were identified as associated factors for more serious degeneration of SIJ among patients with LDH. Limitations: The main limitation of this study was the retrospective observational nature. Hence our study described that SIJ degeneration was relevant to LDH, but the causal relationship was uncertain. Magnetic resonance imaging was not chosen in this study. Conclusions: The SIJ degeneration in patients with LDH was more serious than in individuals without LDH. SIJ degeneration was more significant in patients with LDH with more pathological alterations, symptoms, and complications. Age and LDH relate to SIJ degeneration. Therefore the diagnosis and selection of treatment for SIJ changes should comprehensively consider the coexistence of LDH. Key words: Lumbar disc herniation, low back pain, sacroiliac joint, degeneration, sciatica, numbness, weakness, cauda equina syndrome, computed tomography, linear mix model

Background: Intradiscal ozone therapy, a minimally invasive technique, is used in patients that do not respond to standard conservative therapies for low back pain due to degenerative disc-induced lumbar disc herniation (LDH). Many studies on clinical efficacy lack a standardized injection method and are limited by inadequate study design. Objective: This study aimed to determine the efficacy of periforaminal steroid injection together with intradiscal ozone therapy. Study Design: A prospective, double-blinded, randomized controlled trial. Setting: A tertiary care center. Methods: This study was conducted in 65 patients with low back and leg pain caused by LDH. Group 1 received intradiscal ozone therapy (n = 35) and Group 2 received intradiscal ozone therapy with periforaminal steroid injection (n = 30). Patients were evaluated for pain using the visual analogue scale (VAS), for disability using Oswestry Disability Index (ODI), and for quality of life using the short form 36 health survey administered pre-injection and at one and 6 months postinjection. All procedures were performed under sterile conditions using C-arm fluoroscopy. Results: Significant improvements were observed in pain, disability, and quality of life in both groups post-treatment compared to pre-injection. Mean pre-injection VAS was not significantly different between the groups (VAS: 7.8 ± 1.1 for Group 1, 7.8 ± 1.2 for Group 2). VAS values at 6 months for Group 1 and Group 2 were as follows: 3.6 ± 2.4, 4.1 ± 1.6, respectively) (P < 0.001). Mean pre-injection ODI was not significantly different between the groups (ODI: 20.9 ± 9.6 for Group 1, 25.2 ± 10.3 for Group 2). ODI values at 6 months for Group 1 and Group 2 were as follows: 12.8 ± 9.2, 14.3 ± 7.2, respectively) (P < 0.001). However, there were no significant differences between the groups. Similarly, there was no significant difference between the 2 groups on any of these parameters. Limitations: A limited number of patients and limited follow-up time. Conclusion: This study showed that intradiscal ozone injection alone was sufficient to treat low back and leg pain caused by LDH and that periforaminal steroid injection does not provide additional benefit, which is contrary to the literature. Key words: Low back pain, intradiscal ozone, steroid, lumbar disc herniation, lumbar disc degeneration

Background: Foraminal stenosis, defined as a narrowing of the cervical neural foramen, is one of the most common causes of upper extremity radicular pain. Objectives: The aim of our study was to determine the effects of the severity of neural foraminal stenosis and spinal herniation level on treatment success in patients treated with interlaminar epidural steroid injections (ILESI) due to cervical disc herniation-related radiculopathy and their possible predictive roles. Study Design: A retrospective assessment. Setting: A university hospital interventional pain management center. Methods: We performed our study between August 2017 and February 2019, retrospectively. All patients’ demographic characteristics, clinical and demographic data, including pain scores before and after cervical ILESI in the first hour, third week, and third month follow-ups, presence of motor deficits, symptom side, symptom duration before cervical ILESI, and whether there was progression to surgery in the 3-month period after injection, were collected. Results: We evaluated 61 patients in the final analysis. When the spinal herniation levels and foraminal stenosis grades were compared, there was a significant difference between the groups (P = 0.003, P = 0.005). We reported significant correlations between foraminal stenosis grade (odds ratio [OR], –0.425, P = 0.038) and spinal herniation level (OR, –0.925, P = 0.001) and treatment success. Limitations: Our study’s design was retrospective. Conclusions: Cervical ILESI is a reliable treatment option that provides a significant reduction in pain of patients with cervical radiculopathy. However, the success of ILESI treatment may be negatively affected in these patients in the presence of high spinal level cervical disc herniation and severe foraminal stenosis. Therefore considering these 2 parameters in predicting the patient population who will benefit from cervical ILESI is of importance in terms of decreasing potential complications. Key words: Interlaminar epidural steroid injections, foraminal stenosis, spinal level, cervical disc herniation, radicular pain

Background: Cauda equina syndrome (CES) is a rare and serious syndrome that requires urgent surgery to improve neurological symptoms. CES can be caused by lumber disc herniation (LDH) and accounts for about 1% to 3% of all cases of disc herniation. Objectives: The purpose of this study was to analyze the characteristics and outcomes of the cases of patients with CES caused by LDH and treated by percutaneous endoscopic lumbar discectomy (PELD). Study Design: This study used a retrospective design. Setting: Research took place at the Jiangyin Hospital affiliated with Nanjing University of Chinese Medicine, Jiangsu, China. Methods: This was a retrospective study of patients treated for CES due to LDH with PELD as an emergent surgery at a single institutional department between January 2015 and March 2018. The following variables were analyzed: age, gender, the level of disc prolapse, time interval between diagnosis and surgery, lower extremity pain or weakness, perianal sensation, voluntary anal contraction, presence of bladder dysfunction, and the reversal of these deficits in follow-up. Results: After the emergent surgery with PELD, the lower extremity symptoms were all completely recovered or partly decreased. Only one patient had weakness with plantar flexion of the left foot at the one-year time point. The decreased perianal sensations were partly recovered after surgery, and 9 cases had complete recovery and 2 cases had partial recovery at the one-year follow-up. No patients had anal contraction and bladder problems after the one-year follow-up. Limitations: The number of cases reported here is limited, so we will expand the study by including an increased number of patients and a longer follow-up duration. Conclusion: Taken together, these observations show that PELD, used as a minimally invasive choice of emergent surgery, can provide enough decompression of disc prolapse and a satisfactory outcome for patients with CES caused by LDH. Key words: Cauda equina syndrome, lumbar disc herniation, outcomes, percutaneous endoscopic lumbar discectomy

Lumbar disc herniation (LDH) is the most common cause of sciatica. Percutaneous endoscopic discectomy (PELD) is indicated when conservative treatments fail, which has been proved effective. During conventional PELD, ruptured discs and loose fragments inside discs are removed as much as possible to guarantee a lower reherniation rate, but it inevitably would lead to deterioration of disc degeneration and loss of disc height after PELD. Ensuring sufficient decompression while alleviating the post-operation disc degeneration process is still a clinical problem.To evaluate the imaging and clinical outcomes of bi-needle PELD with intradiscal irrigation technique for the treatment of lumbar disc herniation (LDH).Multicenter retrospective cohort study.Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China.A total of 48 patients who underwent bi-needle PELD (B-PELD) or conventional-PELD (C-PELD) for LDH in our 2 spine centers were included in this study. There were 26 cases in the C-PELD group (male 12 cases, female 14 cases) with an average age of 34.6 ± 6.8 years. And there were 22 patients in the B-PELD group (male 10 cases, female 12 cases) with an average age of 35.1 ± 6.4 years. The difference in postoperative disc degeneration (Pfirrmann grades, disc-vertebra height ratios [D-V H ratios]), visual analog scale (VAS) of low back pain, and reoperation rates were compared between the 2 groups.There was no significant difference in gender, age, disease duration, and surgical level between the 2 groups (P0.05). The postoperative VAS of back pain was 2.31 ± 0.53 for the C-PELD group and 0.63 ± 0.74 for the B-PELD group; the difference was significant (P = 0.013). The difference between the preoperative and postoperative D-V H ratios in the C-PELD group was significant (P0.0001), while it was not significant in the B-PELD group (P = 0.6708). The difference between the loss of D-V H ratios after surgery was significant between the 2 groups (P = 0.0003). The loss of D-V H ratios was higher in the C-PELD group. The difference between the preoperative and postoperative Pfirrmann grades in the B-PELD group was not significant (P = 0.7261); however, it was significant in the C-PELD group (P = 0.0012). The reoperation rate in the C-PELD group was 7.7%, and the reoperation rate in the B-PELD group was 4.5%; the difference was not significant (P = 1).This study employed a retrospective design, and its inherent selection bias and limited statistical power should be considered.Bi-needle technique with saline irrigation maneuver showed a significant advantage of restoration of disc height and amelioration of disc degeneration compared to conventional PELD surgery.

Percutaneous endoscopic lumbar discectomy (PELD) has become a mature and mainstream minimally invasive surgical technique for treating lumbar disc herniation (LDH). During PELD, various spinal structures, such as ligamentum flavum, dural sac, nerve root, posterior longitudinal ligament, annulus fibrosus, and endplate, were exposed, removed, and decompressed. When we used different endoscopic instruments to touch, remove, and excise different spinal structures, the patient will experience varying degrees of low back pain (LBP). To the best of our knowledge, the differences of the LBP have not been investigated in detail.To evaluate the spinal structures pain variability during PELD.A retrospective study.All data were collected from Shandong Provincial Hospital Affiliated to Shandong First Medical University.From February 2017 to May 2021, 1,100 patients with LDH underwent PELD surgery. During the operation, the Visual Analog Scale (VAS) was used to assess the pain intensity of each patient, generated by physical stimuli of different endoscopic instruments (i.e., nucleus pulposus forceps, punch forceps, and radiofrequency bipolar coagulator) in different tissue (i.e., posterior longitudinal ligament, nerve root /dural sac, endplate, and ligamentum flavum). Data were analyzed by analysis of variance with Bonferroni post hoc tests.As for the VAS for LBP among different spinal tissues, the degree of LBP was reduced in each group in the following order (decreasing from most severe to mildest): posterior longitudinal ligament, nerve root/dural sac, endplate, ligamentum flavum, annulus fibrosus (P0.01). As for the VAS for LBP caused by different endoscopic instruments, we found the most intense LBP always caused by nucleus pulposus forceps, next by punch forceps, then by radiofrequency bipolar coagulator (P0.01).The retrospective nature of data collection and the educational discrepancies among the trial population may affect data collection to some extent.During PELD, varied LBP will generate when different spinal tissues are manipulated by different endoscopic instruments, the most severe LBP always came from the posterior longitudinal ligament and nerve root /dural sac. Moreover, compared to incision and thermal stimulus, traction could provoke more severe LBP.

Percutaneous endoscopic lumbar discectomy (PELD), as a representative minimally invasive spine surgery technique for lumbar disc herniation (LDH), has been standardized. In PELD, tissues such as ligamentum flavum, dural sac, nerve root, posterior longitudinal ligament, annulus fibrosus, and endplate were exposed, removed, and decompressed. However, during PELD, whether there is pain or not in the tissues under endoscope in LDH patients has never been thoroughly discussed in the previous research.The purpose of the study is to evaluate tissue pain variability during PELD as for the treatment of LDH, to provide references and guideline for the operation, and to give humanistic care for patients.A retrospective analysis.All data were collected from Shandong Provincial Hospital Affiliated to Shandong First Medical University.From January 2008 to December 2020, 3,600 patients with LDH were enrolled in this retrospective study. All patients suffered from low back and leg pain because of LDH and underwent PELD. The pain of these tissues under endoscope was assessed according to the Visual Analog Scale (VAS) scores for the back and legs (VAS-B and VAS-L, respectively).For VAS-B, the tissues were ranked from the highest VAS scores to the lowest in the following order: posterior longitudinal ligament; next, dural sac/nerve root; then, endplate/annulus fibrosus/ligamentum flavum. For VAS-L, they were in the following order: dural sac/nerve root; next, posterior longitudinal ligament; then, endplate/annulus fibrosus/ligamentum flavum.Retrospective nature of data collection.Tissues, such as ligamentum flavum, dural sac, nerve root, posterior longitudinal ligament, annulus fibrosus, and endplate, have different kinds of pain in PELD for LDH.

BACKGROUND: The Best Practices in Pain Management from the U.S. Department of Health and Human Services (HHS) describes interventional techniques as part of a continuum. Epidural injections are commonly utilized modalities in managing low back and lower extremity pain. Epidural injections were initially administered in 1901 where the first descriptions of caudal epidural with local anesthetic for low back pain appeared. Since then, multiple developments have occurred. Currently, epidural injections are provided by caudal, interlaminar, and transforaminal approaches. The comparative effectiveness of each modality has been studied. However, comparative assessment has been sparse. OBJECTIVES: To assess the efficacy of 3 routes of administration of epidural injections for lumbar disc herniation. STUDY DESIGN: A systematic review and meta-analysis of randomized controlled trials (RCTs) of transforaminal, interlaminar and caudal epidural injections in managing chronic low back and lower extremity pain due to lumbar disc herniation. METHODS: RCTs with a placebo control or an active control design, performed under fluoroscopic guidance, with at least 6 months of follow-up are included. The outcome measures were pain relief and functional status improvement. Significant improvement was defined as 50% or greater pain relief and functional status improvement. Data extraction and methodological quality assessment were performed. Evidence was summarized utilizing principles of best evidence synthesis. RESULTS: A total of 21 trials were included. Of these, 7 studied caudal epidural injections, whereas transforaminal epidural injections were studied in 12 trials, and lumbar interlaminar epidural injections were studied in 10 trials, which all met inclusion criteria. Based on qualitative and quantitative analysis, which included conventional dual-arm and single-arm analysis for interlaminar epidural injections, and single-arm analysis for caudal and transforaminal epidural injections, and the approach to the epidural space, there is Level I evidence for local anesthetic and steroids, Level II for local anesthetic alone for transforaminal and interlaminar approaches, and Level II for the caudal approach with steroids or local anesthetic alone for short- and long-term relief. LIMITATIONS: There is a paucity of literature with intermediate or long-term relief of at least 6 months with appropriate outcome parameters. Conventional dual-arm meta-analysis was feasible only for interlaminar epidural injections. CONCLUSION: Epidural injections with local anesthetic and steroids showed Level I evidence for transforaminal and interlaminar approaches, whereas with local anesthetic alone Level II evidence was demonstrated. In contrast, caudal epidural injections showed Level II evidence with local anesthetic with steroids or local anesthetic alone. KEY WORDS: Chronic low back pain, lumbar radiculopathy, lumbar disc herniation, sciatica, epidural injections, local anesthetic, steroids, caudal epidural injections, interlaminar epidural injections, transforaminal epidural injections

Studies that focus on percutaneous full-endoscopic anterior transcorporeal cervical discectomy (PEATCD) have rarely been reported. Therefore, the available data on the surgical design of PEATCD and related clinical outcomes are very limited.To design a surgical plan for PEATCD and to evaluate its clinical efficacy in clinical application.A retrospective cohort study.A center for spine surgery, rehabilitation department and pain medicine.Based on the size and precise location of the disc protrusions on magnetic resonance imaging (MRI), the diameter and direction of the bone channel were designed to make a surgical plan for PEATCD. A total of 26 patients with central/paracentral cervical disc herniation (CDH) who underwent PEATCD through the designed surgical plan from October 2015 to September 2016 were enrolled in the retrospective study. Clinical outcome evaluations included Visual Analog Scale (VAS) scores, Japanese Orthopedic Association (JOA) scores, and the modified Macnab criteria. Radiologic follow-up included cervical computerized tomography (CT) and MRI evaluations.The diameter of the designed bone channel was about 7.5 mm, and the direction was from the upper edge of the lower endplate obliquely toward the disc protrusion. Through the designed surgical plan, 26 cases of discectomy were successfully completed. The average operation time was 91.50 ± 16.80 min, and the average hospital stay was 4.07 ± 0.84 days. All patients were followed for an average of 19.61 ± 4.04 months. The postoperative VAS and JOA scores were significantly improved compared with the preoperative scores (P0.0001). Clinical efficacy at the final follow-up was evaluated by the modified Macnab criteria, and the excellent and good rate was 92.31%. Postoperative MRI showed that the disc protrusion was completely removed, and CT showed no collapse of the vertebral body.This study has several limitations, including the lack of a control group, the small sample size, and the unavoidable nature of the single-center study design.Based on the size and location of the disc protrusion on MRI, the diameter and direction of the bone channel are designed, which is conducive to have enough space under the full-endoscopic field of view to completely expose and remove the disc protrusion, to avoid residuals, and to ensure that PEATCD achieves good therapeutic results.The study was registered at Chinese Clinical Trial Registry (ChiCTR1900027820).

There have been several recent reports of lumbar disc herniation (LDH) resorption; however, large sample studies are lacking, and the mechanism(s) underlying this phenomenon is unclear.To explore the feasibility and clinical outcomes of conservative treatment for giant LDH and to analyze the factors affecting the resorption of giant LDH.Observational study and original research.This work was performed at a University Hospital of Traditional Chinese Medicine, Nanjing University of Traditional Chinese Medicine.From January 2008 to December 2019, 409 patients with giant LDH who initially underwent nonsurgical treatment in our hospital were followed for 1-12 years to analyze the rate of surgical intervention, calculate the rate of resorption of protrusions, and the rate of excellent clinical outcomes.Eighty-nine of the 409 patients (21.76%) underwent surgery, while the remaining 320 patients (78.24%) constituted the non-surgical treatment group. The Japanese Orthopaedic Association (JOA) score in the 320 patients changed from 10.22 ± 3.84 points to 24.88 ± 5.69 points after treatment, and the rate of excellent outcomes was 84.06%. Among the 320 patients in the non-surgical treatment group, the protrusion percentage decreased from 70.08±30.95% to 31.67 ± 24.42%. One-hundred and eighty-nine patients (59.06%) had30% resorption of protrusions, and 81 patients (25.31%) had a significant resorption of protrusions of50%. Among 189 patients with resorption, the shortest resorption interval was 1 month, and the longest was 8 years, with 77 patients (40.74%) showing resorption within 6 months, 51 (26.98%) within 6-12 months, and 61 patients (32.28%) after 12 months.The main limitations are that all patients were from the same site, and there was a lack of multicenter randomized controlled trials with which to compare data.Patients with giant LDH are less likely to develop progressive nerve injury and cauda equina syndrome if their clinical symptoms improve after treatment. As long as there is no progressive nerve injury or cauda equina syndrome, conservative treatment is preferred for giant disc herniation. Resorption is more likely with greater disc protrusions in the spinal canal. A ring enhancement bull's eye sign) around a protruding disc on enhanced magnetic resonance imaging is an important indicator of straightforward resorption.

No long-term follow-up data exist in any treatment for chronic radicular pain occurring with disc pathology and after failed back surgery. A previous randomized controlled trial (RCT) has proven efficacy in short-term follow-up as an evidence-based effective therapeutic option.Long term data is needed to determine the efficacy and cost- effectiveness of minimal invasive procedures. The present study reports 10 year follow-up results from the randomized trial.A prospective, randomized, placebo-controlled, interventional clinical trial. A power calculation was based on a previous feasibility trial.University medical centers.After a 4 year enrollment phase, 381 patients with chronic radicular pain persisting beyond 4 months, who failed conservative treatments, were screened. Ninety patients were enrolled. Patients were randomly assigned to receive percutaneous epidural lysis of adhesions or placebo with concealed allocation in permuted blocks of 4 to 8 patients each, and stratified by treatment center. The primary outcomes were a mean change of the Oswestry Disability Index (ODI) scores and Visual Analog Scale (VAS), one and 10 years after intervention. For each rating scale an analysis of variance with the within-patient factor time (baseline, one year follow-up, 10 year follow-up) and the between-patient factor treatment (lysis, placebo) was used.Homogeneity was shown at baseline between the groups. The ODI and VAS scores were significantly better one and 10 years in the lysis group vs the control group. The ODI in the lysis group improved from 55.3 ± 11.6 to 9.6 ± 9.3 after one year and to 11.7 ± 14.2 after 10 years. The placebo group also improved from 55.4 ± 11.5 to 30.7 ± 14.2 after one year and to 24.8 ± 12.0 after 10 years. The VAS improved from 6.7 ± 1.1 to 1.2 ± 1.1 after one year and to 1.5 ± 1.4 after 10 years in the lysis group and from 6.7 ± 1.1 to 2.8 ± 1.5 after one year and to 2.9 ± 1.3 after 10 years after placebo intervention. The statistical difference of the ODI and VAS between the treatment and control groups remain significant up to 10 years. No treatment-related severe adverse effects occurred within the 10 years, but minor transient neurological effects were seen directly after the intervention.The long-term effects of single treatment components cannot be specified as no imaging examination was performed at 10 year follow-up. A large variety of unanalyzed noninvasive treatments were done within the 10 years. Some patients did not clearly remember the intervention after 10 years. Uncontrolled effects such as higher inhomogeneity of biometric properties, concomitant therapies, pain tolerance level, or just social effects could occur, but were not analyzed in the trial.This is the first 10 year follow-up report of a placebo-controlled RCT showing efficacy of the minimally invasive percutaneous adhesiolysis procedure for patients with chronic lumbosacral radicular pain. No alternative evidence-based treatment modality with 10 year follow-up is available to be recommended. This procedure should be considered as the first treatment option for patients with chronic lumbosacral radicular pain.

Although many studies have compared full endoscopic spine surgery and open spine surgery, few have compared the outcomes of percutaneous endoscopic interlaminar lumbar discectomy (PEILD) and open lumbar microdiscectomy (OLM) at the L5-S1 level.We compared the clinical, surgical, and radiological outcomes of patients with disc herniation at the L5-S1 level who underwent either PEILD, or OLM, performed by a single surgeon with novice-level proficiency.Observational, retrospective matched cohort design.An analysis of clinical data was performed at a single center, collected from September 2012 to August 2016.The study enrolled 56 patients who underwent discectomy at the L5-S1 level, with a minimum one-year follow-up. Patients were allocated to 2 groups: a PEILD group (n = 27; September 2014 to August 2016), or an OLM group (n = 29; September 2012 to August 2014). Clinical, surgical, and radiological outcomes were retrospectively evaluated.Baseline characteristics including age, gender, past medical history, body mass index, preoperative symptom, and preoperative radiological findings did not differ significantly between the groups. Further, overall clinical outcomes including back and leg pain; surgical outcomes including blood loss, complication rate, and recurrence rate; and radiological outcomes including degree of decompression, disc height, and sagittal alignment were not different significantly between the 2 groups.However, the PEILD group showed significant advantages including lower immediate postoperative back pain (mean 1.44 [95% confidence interval (CI), 1.16-1.72] versus 2.41 [95% CI, 2.14-2.69], P0.001), favorable immediate postoperative Odom's criteria (excellent 57.14% versus 24.14%, P = 0.025), shorter operation time (mean 63.89 ±17.99 minutes versus 109.66 ±31.42 minutes, P0.001), shorter hospital stay (3.15 [95% CI, 2.21-4.09] days versus 5.72 [95% CI, 3.29-8.16] days, P0.001), and rapid return to work (15.67 [95% CI, 12.64-18.69] days versus 24.31 [95% CI ,19.97-28.65] days, P = 0.001).Due to its retrospective nature, it was not possible to control for all variations. Moreover, the number of patients in the final cohort was relatively small.Our findings indicate that the PEILD group achieved better perioperative outcomes despite no significant intergroup difference in mid-term clinical and radiological outcomes.

New approaches and technologies can be beneficial for patients but also bring corresponding complications. Traditional pairwise meta-analyses cannot be used to comprehensively rank all surgical approaches.The purpose of this systematic review and network meta-analysis (NMA) was to compare the outcomes of different surgical approaches for lumbar disc herniation (LDH).NMA of randomized controlled trials (RCTs) for multiple treatment comparisons of LDH.The PubMed, Embase, MEDLINE, Ovid, and Cochrane Library databases were searched for RCTs comparing different surgical approaches for patients with LDH from inception to February 10, 2020. The Markov chain Monte Carlo methods were used to perform a hierarchical Bayesian NMA in WinBUGS version 1.4.3 using a random effects consistency model. The primary outcomes were disability and pain intensity. The secondary outcomes were complications and reoperation. The PROSPERO number was CRD42020179406.A total of 22 trials including 2529 patients and all 5 different approaches (open discectomy or microdiscectomy [OD/MD], microendoscopic discectomy [MED], percutaneous endoscopic discectomy [PED], percutaneous discectomy [PD], and tubular discectomy [TD]) were retrospectively retrieved. PED had the best efficacy in improving patients' dysfunction with no statistical significance (probability = 50%). PD was significantly worse than OD/MD, MED, and PED in relieving patients' pain (standardized mean differences: 0.87 [0.03, 1.76], 0.94 [0.06, 1.88], and 1.02 [0.13, 1.94], respectively). There was no statistically significant difference between any 2 surgical approaches in dural tear; intraoperative, postoperative, and overall complications; or reoperation rate. PED had the lowest dural tear rate and the lowest intraoperative and overall complication rates (probability = 51%, 67%, and 33%, respectively). TD had the lowest postoperative complication and reoperation rates (probability = 35% and 39%, respectively).The limitations of this NMA include the inconsistent follow-up times, the criteria for complications, and the reasons for reoperation.Compared with other approaches used to treat LDH, PED had the best safety and efficacy in general, and TD had the lowest reoperation rate. Finally, we recommended PED for LDH.

Background: Groin pain can be induced by high-level (L1-L2 or L2-L3) lumbar disc herniation. However, 4.1% of patients with lower-level (L4-L5 or L5-S1) lumbar disc herniation also complained of groin pain. The pathomechanism of groin pain occurring due to lumbar disc herniation at and below the L4-5 levels is still unclear. Objective: To investigate the afferent pathways of lower-level lumbar disc herniation induced groin pain. And evaluate the clinical results of transforaminal endoscopic discectomy treatment for discogenic groin pain. Study Design: This retrospective observational study used an experimental design (institutional review board: HROH 201-C2-100). Setting: The research took place in the Laboratory Research Center and spine center at The First Affiliated Hospital of Harbin Medical University. Methods: Firstly, 14 adult Wistar rats were randomly divided into 2 groups: control group (the paravertebral sympathetic trunks were preserved) and experimental group (the paravertebral sympathetic trunks were resected). All Wistar rats were intraperitoneally anesthetized, and then 1 μL of fast blue was injected into the dorsal rami of L2 spinal nerves on the right side. Forty hours later, 2 μL of nuclear yellow was injected into the right posterior portion of the L5-L6 intervertebral disc. The L1 and L2 spinal ganglia were sectioned 8 hours later to observe fluorescently double-labeled cells and the effect of paravertebral sympathetic trunk resection. Secondly, 14 adult Wistar rats were anesthetized, and the right posterior portion of the L5- L6 intervertebral disc was electrostimulated to observe potential changes in the genitocrural nerve in the ipsilateral inguinal region. To evaluate the clinical outcomes of transforaminal endoscopic discectomy for the treatment of discogenic groin pain, between September 2015 and May 2017, transforaminal endoscopic discectomy was performed on 30 patients with lower-level discogenic groin pain. Outcomes were analyzed utilizing the visual analog scale, Oswestry disability index, and MacNab Criteria. Results: The total proportion of cells in the right L1 and L2 spinal ganglia with fast blue/nuclear yellow double labeling was 3.33% and 3.41% (48 and 56), respectively. The number of fluorescently doublelabeled cells in the resected paravertebral sympathetic trunk group was significantly less (P < 0.01). Electrical stimulation of the right posterior portion of the L5-L6 intervertebral disc could elicit action potentials in the ipsilateral genitofemoral nerve. All patients were followed for 12 months, and the visual analog scale score at 1 week, 1 month, 3 months, 6 months, and 12 months after the operation was 0.79 ± 0.55, 0.54 ± 0.55, 0.47 ± 0.65, 0.51 ± 0.65, and 0.69 ± 0.55, respectively, showing a significant decrease compared with the preoperative visual analog scale score (P < 0.01). Based on the MacNab scoring system, the effective rate was 100%, and the rate of good and excellent results was 93.3%. Limitations: A relatively small number of patients and a short follow-up period. Conclusions: Discogenic groin pain is transmitted by sympathetic nerves and appears in the area segmentally innervated by the anterior rami of the L1 and L2 spinal nerves. Posterolateral percutaneous transforaminal endoscopic discectomy and radiofrequency thermal annuloplasty are effective minimally invasive alternative treatments for discogenic groin pain. Key Words: Discogenic groin pain, percutaneous transforaminal endoscopic discectomy, radiofrequency thermal annuloplasty

Percutaneous transforaminal endoscopic discectomy (PTED) and microendoscopic discectomy (MED) are alternative minimally invasive procedures for the treatment of symptomatic lumbar disc herniation (LDH). However, insufficient literature exists to highlight the differences between the procedures.This study intended to clarify whether PTED results in better clinical outcomes compared with MED in the surgical management of single-level LDH.A multicenter retrospective cohort study.This study took place in 2 spinal minimally invasive centers in Beijing, China.A multicenter retrospective study was conducted in consecutive patients diagnosed with symptomatic LDH receiving PTED or MED in 2 spinal minimally invasive centers from April 2009 to July 2016. A total of 1,053 patients were recruited, of which 632 underwent PTED and 421 underwent MED. All patients were followed with a minimum of 2 years; a set of clinical outcomes were extracted and analyzed.The operation time was similar between groups (71.2 ± 15.1 minutes in the PTED group and 69.4 ± 12.5 minutes in the MED group; P = 0.518); length of incision was significantly shorter; intraoperative blood loss was less in the PTED group (P0.001); hospital stay was 3.6 ± 1.5 days in the PTED group and 5.4 ± 2.8 days in the MED group with significant differences detected (P = 0.018); however, intraoperative fluoroscopy was longer with significantly higher cost with the PTED group (P0.001). Transient dysesthesia and wound complications were more common in the MED group (P = 0.039 and P = 0.026, respectively); however, no significant differences were found with total complications (P = 0.139). Significant lower Visual Analog Scale pain score (back and leg) were detected on day 1 postoperatively (P = 0.007 and P = 0.018, respectively). No significant differences were found at all other time points (P0.05). Significantly better Oswestry Disability Index (ODI) score was detected postoperatively at 1 month in the PTED group (19.6 ± 9.8 vs. 27.2 ± 9.3; P = 0.016); ODI score at other time points did not differ significantly between groups (P0.05). Modified MacNab criteria showed that most patients experienced excellent and good results with no significant differences between groups (P = 0.511).This was a multicenter retrospective study wherein the surgeons may have introduced bias to the study.Both PTED and MED present to be an acceptable long-term efficacy for the treatment of LDH. Although PTED is associated with longer intraoperative fluoroscopy and a little more cost, it should still be considered superior to MED considering the benefits of lesser invasion, shorter hospital stays, quicker pain relief, and functional recovery.

Microendoscopic discectomy (MED) and percutaneous transforaminal endoscopic discectomy (PTED) are 2 of the most popular minimally invasive spinal surgery techniques. We are investigating whether minimally invasive early annular closure can achieve a better clinical effect in the treatment of lumbar disc herniation (LDH).To compare the clinical and imaging outcomes between MED combined with annular suture and PTED in the treatment of LDH.A prospective observational study with follow-up of 36 months.The First People's Hospital of Lianyungang in China.A total of 135 prospective consecutive patients underwent MED + annular suture or PTED. Patients were assessed postoperatively at 3 days and 3, 6, 12, 24, and 36 months. The outcome measures were visual analog scales for back pain (VAS-back) and leg pain (VAS-leg) scores, the Oswestry Disability Index (ODI) score, the Medical Outcomes Study 36-Item Short-Form Health Survey bodily pain (SF36-BP), and physical function (SF36-PF) scales, disc height, and recurrence rate.One hundred and six patients have completed the 3-year follow-up. The operation time and length of stay in the MED + annular suture group were longer than that in the PTED group (P0.001 and P0.001). VAS-back score, VAS-leg score, ODI score, SF36-BP, and SF36-PF significantly improved at follow-up time points after surgery compared to before surgery, but no significant differences were found at postoperative and 36 months between the groups. The disc height in the MED + annular suture group was significantly greater than that in the PTED group after 3 months. Within 36-month follow-up, imaging re-herniation was reported in 4 patients in the MED + annular suture group, and 9 patients in the PTED group (P = 0.170). Symptomatic re-herniation occurred in one patient in the MED + annular suture group and in 4 patients in the PTED group (P = 0.190).First, this was not a randomized controlled trail, which could provide more evidence-based conclusions. Second, we did not accurately measure and compare the amount of nucleus pulposus removed, although less nucleus pulposus was removed in MED + annular suture.PTED has the advantages of shorter length of incision, shorter operation time, and shorter length of stay. MED + annular suture is associated with greater preservation of disc height, and showed certain advantages of lower recurrence rate, although there was no statistical difference.

The lateral fusion procedure is a newer minimally invasive approach to indirectly decompressing and fusing a lumbar motion segment. As with many new procedures, new thoughtful approaches to recognizing and treating the complications of these procedures need to be developed.Here we describe our experience with transforaminal endoscopic decompression for complications of lateral and oblique lumbar fusion.Retrospective case review.This was a multicenter study that took place in an academic hospital, community hospital, and ambulatory surgery center.An endoscopic treatment technique for 4 types of complications associated with lateral and oblique fusion is presented. We retrospectively reviewed cases at 3 centers in 2 countries of patients who underwent transforaminal endoscopic surgery for the treatment of lateral fusion complications in a 4-year period with a minimum follow-up of 1 year.A preliminary series of 4 patients with an average age of 74.8 years (range, 69-82 years) who underwent transforaminal endoscopic procedures at the level of their lateral and oblique lumbar fusions between 2014 and 2018 is presented. Disc herniations, heterotopic bone formation, endplate fracture, and nerve root impingement by the interbody device were all treated endoscopically.Small case series evaluated retrospectively with 1-year follow-up.Transforaminal endoscopic surgery is a useful minimally invasive surgical technique to treat several complications associated with lateral and oblique lumbar interbody fusion procedures.

A severe grade I and grade II spondylolisthesis at L5-S1 creates an anatomic distortion that can compress the traversing S1 nerve with a retropulsed S1 vertebral body endplate and (sometimes) herniated disc.To evaluate the feasibility for awake, endoscopic treatment of symptomatic radiculopathy secondary to the deformity that results from the retropulsed superior endplate of S1 in grade I/II L5-S1 spondylolisthesis in patients with and without previous fusion surgery.Retrospective chart review.This study took place in a single-center, academic hospital.In 325 patients over 4 years there were 19 patients (8 with previous L5-S1 fusions and 11 without) treated with transforaminal endoscopic spine surgery for decompression of the neural foramen at L5-S1 in the setting of spondylolisthesis (at least 5 mm) and a retropulsed superior vertebral endplate of S1.The average preoperative Visual Analog Scale (VAS) back and leg scores were 6.1 and 6.7, and the average preoperative Oswestry Disability Index (ODI) score was 50.4. The average 1-year VAS back and leg scores were 2.2 and 2.2, and the average 1-year postoperative ODI score was 20.5. There was no statistically significant difference between the fusion and nonfusion groups. Patients treated were patients who presented with an S1 or L5 and S1 radiculopathy as their primary complaint and a L5-S1 spondylolisthesis of 5 mm or greater. Patients treated had no instability on flexion-extension x-rays. Eleven patients had not had fusions at L5-S1, and 8 patients had previous fusions at L5-S1 but still had a spondylolisthesis of at least 5 mm. The average slip for nonfusion patients was 8.4 mm, and the average slip for fusion patients was 8.8 mm. At 1-year follow-up the improvement in VAS back scores was 44% in the nonfusion group and 49% in the fusion group, and the improvement in VAS leg scores was 84% in the nonfusion group and 58% in the fusion group. At 1-year follow-up the improvement in ODI scores was 63% in the nonfusion group and 54% in the fusion group.Retrospective case series.Awake, endoscopic surgery for the treatment of radiculopathy in the setting of a grade I/II L5-S1 spondylolisthesis is a viable minimally invasive treatment option for patients with radiculopathy in the setting of a stable L5-S1 spondylolisthesis with foraminal narrowing caused by a retropulsed superior endplate of the S1 vertebral body.

Cervical radicular pain (CRP) is a common problem in the adult population. When conservative treatment fails and the severe pain persist, surgical treatment is considered. However, surgery is associated with some serious risks. To reduce these risks, new minimally invasive techniques have been developed, such as percutaneous nucleoplasty. Several studies have shown that percutaneous nucleoplasty is a safe and effective technique for the treatment of CRP, but until now no randomized controlled trials have been conducted that compare percutaneous cervical nucleoplasty (PCN) to anterior cervical discectomy (ACD) in patients with a single-level contained soft-disc herniation.To compare the effects of PCN and ACD in a group of patients with CRP caused by a single-level contained soft-disc herniation.A randomized, controlled, multi-center trial.Medical University Center and local hospitals.Forty-eight patients with CRP as a result of a single-level contained soft-disc herniation were randomized to one of the following 2 treatments: PCN or ACD. The primary outcome measure was arm pain intensity, measured with a Visual Analog Scale (VAS). Secondary outcomes were arm pain intensity during heavy effort, neck pain, global perceived effect, Neck Disability Index (NDI), and the patients' general health (Short Form Generated Health Survey [SF-36]). All parameters were measured at baseline (T0), 3 months after intervention (T2), and one year after intervention (T3). One week after the intervention (T1), an intermediate assessment of arm pain, arm pain during heavy effort, neck pain, satisfaction, and improvement were performed.At 3 months, the intention to treat analyses revealed a statistical significant interaction between the groups on the primary outcome, arm pain intensity, and on the secondary outcome of the SF-36 item pain, in favor of the ACD group. On the other secondary outcomes, no statistical significant differences were found between the groups over time. At 12 months, there was a trend for more improvement of arm pain in favor of the ACD group and no statistical interactions were found on the secondary outcomes.Firstly, the inclusion by the participating hospitals was limited. Secondly, the trial was ended before reaching the required sample size. Thirdly, at baseline, after the inclusion by the neurosurgeon, 13 patients scored less than 50.0 mm on the VAS. Fourthly, the withdrawal of the physiotherapy (PT) group and finally, the patients and interventionists could not be blinded for the treatment.At 3 months, the ACD group performed significantly better on arm pain reduction than the PCN group in patients with CRP as a result of a single-level contained soft-disc hernia. However, the clinical relevancy of this treatment effect can be debated. For all parameters, after one year, no significant differences between the groups were found. When it comes to the longer-term effectiveness, we conclude that PCN can be a good alternative for ACD.

Background: An annulus fissure or defect will inevitably be left on the posterior annulus fibrosus after almost all kinds of lumbar discectomy, which may lead to unsatisfying postoperative pain relief and recurrence of the disc herniation. Objective: The objective of this research is to introduce the technique of full-endoscopic annulus fibrosus suture following lumbar discectomy through the transforaminal or interlaminar approach, and to analyze the clinical outcome of full-endoscopic lumbar discectomy and annulus fibrosus suture. Study Design: This study used a prospective cohort design. Setting: The research was conducted in a hospital and outpatient surgery center. Methods: A total of 50 patients with noncontained lumbar disc herniation treated with full-endoscopic lumbar discectomy and annulus fibrosus suture were treated in our department between January 2018 and November 2018. Full-endoscopic single-stitch suture via the transforaminal approach (Group T) or double-stitch suture via the interlaminar approach (Group I) was selected according to the level of lesion. Lumbar magnetic resonance imaging (MRI) was reexamined on the second day and 3 months after operation to evaluate the completeness of the discectomy and the adequacy of nerve decompression. Patients were followed up on the second day, 3 months, 6 months, and one year after operation to evaluate the relief of low back pain and leg pain, using a visual analog scale (VAS, 100-point scale). At 3 months, 6 months, and one year after operation, the patients were followed up for recovery of lumbar spine function, using the Oswestry Disability Index (ODI). At the one-year follow-up, the MacNab score was used to evaluate the clinical outcome, and the recovery of nerve root function (sensation, muscle strength, and reflex) was recorded. Results: All operations were successfully completed, including 27 cases in Group T and 23 cases in Group I. There were no surgical complications and no recurrence of lumbar disc herniation. Lumbar MRI reexaminations of all patients showed that the herniated disc was completely removed and the nerves were fully decompressed. Postoperative low back pain and leg pain were significantly relieved, and the ODI score was significantly improved (P < .01) in both groups. At the one-year follow-up, the excellent and good rates as measured by the MacNab score were 92.6% in Group T and 91.3% in Group I with no significant difference between the 2 groups (P > .05). The impaired sensation and muscle strength in the low extremities of evolved nerve root of the 2 groups of patients recovered significantly at the oneyear follow-up (P < .01), but the tendon reflex did not recover significantly (P > .05). Limitations: This is an observational cohort study with relatively small sample sizes and short-term follow-up. Conclusions: Full-endoscopic lumbar discectomy and annulus fibrosus suture through either the transforaminal or interlaminar approach are safe and effective minimally invasive spinal surgery techniques that can reduce the recurrence rate of lumbar disc herniation after full-endoscopic lumbar discectomy. Keywords: Annulus fibrosus suture; full-endoscope; lumbar disc herniation; lumbar discectomy; minimally invasive spinal surgery

Background: Discogenic pain is recognized as the most important and most common cause of low back pain (LBP). Intradiscal pulsed radiofrequency (ID-PRF) is used for the treatment of chronic discogenic pain. Objectives: We investigated the effects of the duration of percutaneous monopolar ID-PRF application on chronic discogenic LBP. Study Design: Retrospective study. Setting: Department of Anesthesiology and Pain Medicine, Neurosurgery at Wooridul Spine Hospital. Methods: Forty-five patients were included in this retrospective study. The patients were assigned into 2 groups according to the duration of the PRF procedure they underwent (7-minute group = 17 patients vs. 15-minute group = 28 patients). The main outcome measures tested were pain score, as determined by the Numeric Rating Scale (NRS-11) and the Oswestry Disability Index (ODI), at baseline, at 2-week, and 6-month follow-up visits. Success was defined as a reduction in NRS11 of 50% or more or an ODI reduction of 40% or more. Results: The mean posttreatment pain scores at 2 weeks and 6 months were significantly lower (P < 0.05) in both groups, but the differences between the groups were not significant. ODI scores were also significantly lower compared with the baseline, but the differences between the groups were not significant. At the 6-month follow-up, 12 patients (70.6%) in the 7-minute group and 20 patients (71.4%) in the 15-minute group reported more than 50% reduction in the pain score (P = 0.16), and there was no significant difference between the 2 groups in the number of patients with more than 40% reduction in ODI score (P = 0.23). Limitations: This study was performed with a small sample size and there was no control group. Additional well-designed and well-controlled studies that include parameters such as the stimulation duration, mode, and intensity of PRF are needed to fully assess the efficiency of ID-PRF. Conclusions: ID-PRF was shown to be effective for the treatment of discogenic LBP regardless of duration of ID-PRF application (7 vs. 15 minutes). Key words: Discogenic pain, pulsed, radio frequency, duration, pain, reduction

Posterolateral endoscopic lumbar discectomy (PLELD) or percutaneous endoscopic lumbar discectomy has been reported to be effective as treatment for herniated lumbar disc in degenerative spondylolisthesis. Few studies have investigated the outcomes of open lumbar microdiscectomy (OLM) and PLELD for antero- and retrospondylolisthesis with mild slippage and instability.We aimed to evaluate the outcomes of OLM and PLELD for antero- and retrospondylolisthesis with mild slippage and instability.This study used a retrospective design.Research was conducted in a hospital and outpatient surgical center.This study enrolled 84 patients aged 20 to 60 years with low-grade degenerative spondylolisthesis who underwent OLM or PLELD for antero- or retrospondylolisthesis at our hospital between March 2007 and August 2014 and who were followed up for at least 3 years. Telephone survey and chart review, with a particular focus on pre- and postoperative radiographic parameters, were conducted. Additionally, patients were invited to undergo reexamination to update their clinical and radiological data.Telephone surveys and clinical/imaging evaluation were conducted on the OLM and PLELD groups at a mean of 71.44 and 74.69 months, respectively. Out of 43 patients who underwent OLM, 34 responded to the telephone survey, 17 of whom then underwent reexamination. Among 41 patients who underwent PLELD, 32 responded to the telephone survey, 19 of whom then underwent reexamination. Based on telephone surveys and patient charts, reoperation at the same vertebral level was confirmed in 8 patients (23.5%) who underwent OLM and one patient (4.4%) who underwent PLELD, with a significantly higher rate of reoperation in the OLM group (P = .028). Vertebral disc height decreased more after OLM than after PLELD. Compared to PLELD, OLM was associated with significantly worse rates of iatrogenic endplate damage, endplate defect scores, and alterations in subchondral bone signal intensity. However, the final clinical outcomes did not differ between OLM and PLELD.The limitations of this study include its relatively small sample size and the possibility of bias owing to nonrandomized patient selection.In patients with spondylolisthesis who have a herniated lumbar disc as mild slippage with instability, PLELD may be a good treatment option to reduce recurrence rates and mitigate disc degeneration. IRB approval number: 2016-12-WSH-011.Anterospondylolisthesis, disc degeneration, endplate, herniated lumbar disc, open lumbar discectomy, percutaneous endoscopic lumbar discectomy, posterolateral endoscopic lumbar discectomy, retrospondylolisthesis, slippage.

Percutaneous endoscopic lumbar discectomy (PELD) via the transforaminal approach is difficult at L5-S1 in patients presenting with high iliac crests (HIC). The conventional wisdom is that measurement using lumbar radiography, computed tomography (CT), or magnetic resonance imaging (MRI) is necessary.The objective of this study was to introduce a lumbo-iliac triangular (LI-Tri) technique based on biplane oblique fluoroscopy and verify whether it facilitated transforaminal PELD for patients with L5-S1 lumbar disc herniation (LDH) combined with HIC.A retrospective analysis.All data were from Honghui Hospital in Xi'an.One hundred patients with L5-S1 LDH combined with HIC were treated with PELD. The LI-Tri technique was used in the first 50 patients (applied group). The other 50 patients were classified as the nonapplied group, in which the conventional technique was performed. Clinical outcome evaluation included Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) scores. The intervals of follow-up were scheduled at 1 day and 1, 3, 6, 12, and 24 months postoperatively.No significant difference was observed with respect to demographic information (P.05, respectively). There were 8 patients in the nonapplied group with difficult punctures. Together with the remaining 50 patients, the puncture was successful with the LI-Tri technique. The mean operative duration was shorter in the applied group (55 vs 70 min, P.01). Compared to the preoperative data, only the back pain VAS and ODI in the nonapplied group were nonsignificantly lower at one day postoperatively (P.05, respectively). With the exception of the back pain VAS and ODI at one day postoperatively, no significant differences were observed in the 3 parameters at other time points postoperatively between 2 groups (P.05, respectively).The study is limited by its retrospective, nonrandomized controlled design.For patients with L5-S1 LDH combined with HIC treated by transforaminal PELD, the LI-Tri technique is simple and effective in preoperative evaluations, locating the skin entry point and guiding the puncture trajectory. Compared to the conventional technique, it shows advantages in terms of reducing intraoperative surgical duration and promoting fast postoperative recovery.Endoscopic discectomy, iliac crest, L5-S1 disc, PELD, percutaneous, transforaminal.

Background: Percutaneous endoscopic lumbar discectomy (PELD) can only relieve mechanical compression but cannot directly reduce the inflammatory reaction of the adjacent nerve root, which contributes to persistent pain and physical disabilities postoperatively. Numerous studies have explored the application of epidural steroids after an open lumbar discectomy in relieving pain by reducing local inflammatory reactions and further peridural scar formation. Objectives: To explore that whether “cocktail treatment” in which a gelatin sponge was impregnated with ropivacaine, dexamethasone, and vitamin B12 promoted early postoperative recovery after PELD. Study Design: Retrospective, case-controlled study. Setting: All data were from Hong-Hui Hospital in Xi’an. Methods: Between January 2016 and January 2017, 100 patients of single-level lumbar disc herniation were treated with PELD in our hospitals. The cocktail treatment was applied in the first 50 patients (group cocktail), and an equal size gelatin sponge without drugs was used in the other 50 patients as control (group noncocktail). The clinical outcome evaluation included the Visual Analog Scale (VAS) score for back and leg pain and Oswestry Disability Index (ODI) score. Results: There was a significant difference in the mean periods of return to work (4.25 ± 1.88 weeks in the cocktail group and 5.18 ± 2.19 weeks in the noncocktail group) (P < 0.01). Compared with the preoperative data, a significant improvement in VAS scores of back pain and sciatica and ODI were observed in each follow-up interval (P < 0.05, respectively). In the noncocktail group, there were visible fluctuations in the 3 indicators within the first week after surgery. This phenomenon was not observed in the cocktail group, a difference that was statistically significant (P < 0.05, respectively). In further follow-up, no significant differences were observed between the 2 groups (P > 0.05, respectively). Limitations: The nonrandomized, single-center, retrospective design is a major limitation of this study. Conclusions: The “cocktail treatment” with a gelatin sponge impregnated with ropivacaine, dexamethasone, and vitamin B12 promotes early and satisfactory back and leg pain relief and fast functional recovery after PELD. Key words: Endoscopic lumbar discectomy, lumbar disc herniation, steroids, nerve root block, gelatin sponge

Background: Percutaneous endoscopic lumbar discectomy (PELD) often refers to percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID). As a minimally invasive spinal procedure, PELD has gained increasing recognition for its small incision, quick recovery, short hospital stay, and equivalent clinical outcome compared to open surgery. In order to obtain satisfactory clinical efficacy, adequate consideration should be given regarding the indication of PELD. On the other hand, complications related to PELD will also significantly affect the safety and outcome of surgery. Objective: Our objective was to conduct a literature review of the indications and complications of PELD and to provide our experience in patient selection and solutions to complications related to PELD. Study Design: The study is a literature review focused on the indications and complications of PELD. Setting: The study is a literature review on the indications and complications of PELD. Methods: A comprehensive review of available literature on PELD was performed. Particular focus was given to the development of indications and prevention of complications. The literature was searched in PubMed database, and key words were set as “percutaneous endoscopic lumbar discectomy”, “percutaneous endoscopic transforaminal discectomy”, “percutaneous endoscopic interlaminar discectomy”, “PELD”, “PETD”, “PEID”, “YESS” and “TESSYS”. Results: PELD is an effective and safe treatment for lumbar disc herniation, lumbar spinal stenosis, recurrent lumbar disc herniation, and other lumbar diseases. Complications related to PELD include dural tear, nerve root injury, recurrence, and so on. Limitations: Some results drawn in this review are based on retrospective study or small sample size. Studies of larger sample size and more multicenter, randomized controlled trials should be conducted to evaluate the clinical efficacy and safety of PELD. Conclusions: PELD is a promising surgical technique for lumbar diseases. Proper patient selection, excellent surgical skills, and rich experience are required for satisfactory outcomes. Key words: Complications, indications, minimally invasive spine surgery, PELD

Scoliosis secondary to lumbar disc herniation (LDH) may occur in both adolescents and adults. As the spine is more flexible in adolescents than in adults, the curve features and curve evolution could be different between these 2 cohorts, which were unclear.To compare the radiologic features of scoliosis secondary to LDH between adolescents and adults, and to further characterize the curve evolution after lumbar discectomy in 2 cohorts.A retrospective study.An inpatient surgery center.Patients with scoliosis secondary to LDH who underwent surgical intervention between 2010 and 2016 were reviewed. Radiographic parameters were measured on standing whole spine radiographs. The apical vertebral translation was measured on serial radiographs taken before surgery, one month and 6 months after surgery, and at last follow-up to evaluate the curve evolution. Meanwhile, the patients' reported outcomes were evaluated. According to age, patients were divided into adolescent and adult group. Comparisons between the 2 groups were made with regards to the preoperative and postoperative radiographic parameters and clinical outcomes.A total of 42 adolescent and 41 adult patients were included in this study. The incidence of scoliosis secondary to LDH in the adolescents was significantly higher than that in the adults. Adolescent patients present remarkably higher incidence of coronal balance as compared with the adult patients preoperatively. No significant difference was observed between the 2 groups in terms of preoperative radiographic parameters. A total of 85.7% of the adolescent patients and 92.7% of the adult patients achieved resolution of scoliosis within 6 months after surgery.This was a retrospective study with a small series of cases and relatively short-term follow-up.The incidence of scoliosis secondary to LDH in adolescents is significantly higher than in adults. Moreover, adolescent patients are more likely to present coronal balance before surgery. The 2 cohorts could have comparable curve evolution, and resolution of scoliosis generally occurred within 6 months after surgery.Sciatic scoliosis, lumbar disc herniation, adolescent, adult, resolution, lumbar discectomy.

Percutaneous endoscopic cervical discectomy has evolved as an efficient, minimally invasive spine surgery for radiculopathy caused by soft and/or osseous foraminal stenosis. Although interlaminar access can be used to resect lateral herniated lesions or osteophytes located in the foramina, with limited operative space, nerve retraction may be unavoidable. This procedure may injure the nerve root and cause postoperative arm pain, numbness, and muscle weakness, especially when the herniation is located in the ventral nerve root or when there is a massive osteophyte in the foramina. However, posterior partial cervical pediculectomy under endoscopy provides a new approach to effectively reduce or even avoid nerve retraction and reduce the potential risk of nerve injury.This report presents a partial pediculectomy approach and compares the clinical outcomes of different surgical methods, including posterior percutaneous endoscopic cervical discectomy (P-PECD) and P-PECD combined with partial pediculectomySTUDY DESIGN: This study used a retrospective comparative study design.This study took place at the Second Affiliated Hospital of Chongqing Medical University.From February 2015 to March 2017, 84 patients with single-level and unilateral soft and/or osseous cervical foraminal stenosis were recruited. Patients were treated with P-PECD (40 patients) and P-PECD combined with partial pediculectomy (44 patients). Postoperative clinical outcomes were assessed using the modified MacNab grading criteria and the Visual Analog Scale (VAS) at different times after surgery. The surgery duration, dosage of postoperative analgesic medication, duration of hospital stay, and postoperative complications were recorded.The mean duration of the conventional P-PECD surgery was 74.48 ± 7.08 minutes, which was significantly longer (P = 0.002) than that observed for the P-PECD with partial pediculectomy (66.00 ± 9.62 minutes). The analgesic dosage in the conventional P-PECD group was significantly higher than that in the partial pediculectomy group (9.14 ± 3.07 units vs. 5.71 ± 3.41 units; P = 0.001). The hospital stay in the conventional P-PECD group was significantly longer than that in the partial pediculectomy group (3.86 ± 0.85 days vs. 3.24 ± 0.83 days; P = 0.022). The VAS scores at 1 day, 3 days, and 7 days after surgery in the conventional P-PECD group were significantly higher than those in the partial pediculectomy group (all P0.001). The modified MacNab grading criteria showed no significant difference at each follow-up (P = 1). The incidence of complications in the P-PECD with partial pediculectomy group (2/44, 4.55%) was significantly lower than that in the conventional P-PECD group (4/40, 10.0%), including complications of increased pain, increased numbness, and worsening of muscle weakness.This study is limited by being a retrospective study, and by having a small sample size and a short follow-up period.As an alternative to the P-PECD surgical technique, P-PECD with partial pediculectomy effectively reduced the postoperative complications and may be preferable when considering the surgery duration, postoperative hospital stay, analgesic dosage, and postoperative VAS score.Cervical disc herniation, foraminal stenosis, percutaneous endoscopic cervical discectomy, PECD, P-PECD, partial pediculectomy.

Background: Transforaminal endoscopic lumbar discectomy (TELD) is regarded as an effective treatment option for soft lumbar disc herniation (LDH). There have been few studies evaluating the long-term outcomes of endoscopic procedures compared with conventional surgery. Objectives: The objective of this study was to demonstrate the clinical outcomes of TELD compared with those of open lumbar microdiscectomy. Study Design: Between January 2009 and September 2011, 335 consecutive patients with symptomatic LDH were treated with decompressive discectomy, either TELD or open microdiscectomy. Patients were prospectively entered into the clinical database and their records were retrospectively reviewed. Setting: Hospital and outpatient surgical center. Methods: Data from 298 patients who were treated with decompressive discectomy, either TELD or open microdiscectomy, were evaluated with a minimum 5-year follow-up period. Among them, 146 patients were treated using TELD (TELD group), and the remaining 152 patients using open microdiscectomy (Open group). Perioperative data and clinical outcomes were evaluated using the visual analog scale (VAS), the Oswestry Disability Index (ODI), and the modified Macnab criteria. Results: The VAS and ODI significantly improved in both groups. The rate of excellent or good outcomes was 88.36% and 87.5% in the TELD and Open group, respectively. The reoperation rate was 4.2% and 3.3% in the TELD and Open group, respectively. There were no significant differences in the clinical outcomes; however, operative time, hospital stay, and time to return to work were significantly shorter in the TELD group (P < 0.01). Limitations: First, the patient selection was not randomized; therefore, the risk of bias might be increased. Second, this study lacks analysis of the radiographic changes related to the degenerative change over the long-term follow-up period. Conclusions: The long-term results of TELD for soft LDH are comparable to those of conventional open microdiscectomy. The selective endoscopic discectomy technique under local anesthesia provides the typical advantages of minimally invasive procedures such as a shorter operation time, hospital stay, and recovery time. Key words: Endoscopic, discectomy, hospital stay, lumbar disc, microscopic, operative time, return to work, transforaminal

Controversy is not uncommon in the diagnosis of discogenic low back pain (DLBP) and in the identification of the location of the pain source for the symptomatic disc in patients with DLBP. Various techniques, from minimally invasive procedures to fusion surgery, are used to treat chronic DLBP, but the clinical outcomes are variable. Percutaneous endoscopic discectomy by transforaminal or interlaminar approach is considered to be an effective method to treat DLBP, but the evidence is limited; the lack of clear evidence may be associated with patient selection and surgical technique.The purpose of this study is to evaluate the clinical results of percutaneous endoscopic treatment for annular tear in selected patients with DLBP by using the outside-in technique.A prospective study and retrospective observations were performed on 24 consecutive patients with a minimum 2 years of follow-up. This study was approved by the Institutional Review Board (IRB) of Buddhist Dalin Tzu-Chi General Hospital Foundation (IRB number: 10504004) and written informed consent was obtained from all patients.This research took place within an interventional pain management and spine practice.Twenty-four consecutive patients with single-level DLBP diagnosed by positive high-intensity zone on magnetic resonance imaging, positive provocative discography, and block test underwent a percutaneous endoscopic procedure from January 2014 to December 2015. The transforaminal approach or interlaminar approach was selected according to the location of the annular tear. The torn lesions were visualized directly and treated by puncture and debridement of the inflammatory tissues from the outer annulus fibrosus to the inner nucleus using the outside-in technique. The Visual Analog Scale (VAS) score and Oswestry Disability Index (ODI) score were evaluated before and after surgery. The clinical global outcomes were assessed on the basis of modified MacNab criteria.These patients included 13 men and 11 women with a mean age of 43.8 years (range, 32-55 yrs). There were 15 lesion levels at L4/L5 and 9 lesion levels at L5/S1. Among them, 15 levels were accessed by transforaminal approach and 9 levels by interlaminar approach. No serious complications were observed during the follow-up periods. All except 2 patients experienced significant symptomatic and functional improvements at the 2-year follow-up with a success rate of 91.7%.Significant limitations include nonrandom format and small sample size. Future research may focus on controlled prospective studies with larger sample sizes and long-term follow-up to examine the validity of this protocol.The percutaneous endoscopic procedure provides a safe and effective treatment for selected patients with DLBP. The outside-in technique allows the surgeons to visualize and treat the torn or inflammatory lesions directly, and the success rate is high at 2 years follow-up.Transforaminal, interlaminar, outside-in technique, endoscopic discectomy, discogenic low back pain.

Transforaminal endoscopic lumbar disc decompression (TELD) has emerged as a treatment alternative to open lumbar discectomy, but rates of herniated lumbar disc (HLD) recurrence after TELD are higher by comparison.We conducted this study to identify factors correlating with early HLD recurrence after TELD.Retrospective study.The Department of Anesthesiology and Pain Medicine, Neurosurgery at Spine Health Wooridul Hospital.As a retrospective review, we examined all patients undergoing TELD between 2012 and 2017, analyzing the following in terms of time to recurrence: age, gender, body mass index (BMI), comorbid conditions (diabetes mellitus [DM], hypertension [HTN]), smoking status, nature of disc herniation (central, paramedian, or foraminal), Modic changes, migration grade (rostral vs. caudal track + degree), herniated disc height (Dht) and base size (Dbase), and the presence of spondylolisthesis on magnetic resonance imaging.During the 5-year study period, 1,900 patients underwent TELD procedures, resulting in 209 recurrences (11.0%). In 27 of these patients (12.9%), herniation recurred within 24 hours after surgery. Recurrences most often developed within 2-30 days (n = 76). The smaller the size of a herniated disc, the earlier it recurred. Recurrences were unrelated to gender, BMI, DM or HTN, smoking status, migration grade, nature (Dht or Dbase of herniated disc), or the presence of spondylolisthesis.In addition to variables assessed herein, other clinical and radiologic parameters that may be important in recurrent disc herniation should be included. Furthermore, only univariate analyses were performed, making no adjustments for potential confounders, therefore, independent risk factors could not be assessed. A prospective study would likely generate more precise results, especially in terms of standardized sampling and data classification. Finally, multiple causes for primary discectomy failures may have rendered our patient groups nonhomogeneous, and inequalities in surgical options or physician-dictated surgical choices may have had an effect.In patients undergoing TELD procedures, smaller-sized herniated discs are linked to early recurrences.Disc herniation, lumbar, endoscopic, recurrence, early.

Foot drop that results from compression of the exiting L5 nerve as a result of far lateral disc herniation (FLDH) at L5-S1 poses a significant surgical challenge to the minimally-invasive spine surgeon given the narrow corridor for an extraforaminal approach because of the high iliac crest.Here we describe our experience with transforaminal endoscopic decompression for the treatment of foot drop secondary to FLDH at L5-S1.Retrospective case review.This study took place in a single-center, academic hospital.A technique for the transforaminal endoscopic treatment of foot drop secondary to L5-S1 FLDH is presented in a series of 5 consecutive patients treated over a period of 3 years. Preoperative and postoperative clinical data with 1-year follow-up are presented.A consecutive series of 211 patients who underwent transforaminal endoscopic treatment for lumbar radiculopathy between 2011 and 2014 are presented. Seventy-seven patients had L5-S1 discectomies and 5 of those patients presented with foot drop and FLDH. The mean visual analog scale score for radicular pain improved from an average pain score before surgery of 7.2 to 0.8 one year after surgery, and the mean motor score for anterior tibialis strength improved from an average motor score before surgery of 2.6 to 4.8 one year after surgery.Small case series evaluated retrospectively with one year follow-up.Transforaminal endoscopic surgical access to FLDH pathology may be a unique approach to the treatment of foot drop because it allows for neural decompression of disc and foraminal pathology without requiring significant destabilizing bone removal.Endoscopic spine surgery, minimally-invasive, transforaminal, foot drop, far lateral disc herniation.

Background: Herniated lumbar discs can induce sciatica by mechanical compression and/ or chemical irritation. It was recently reported that neuroglial cellular activity after pulsed radiofrequency (PRF) application to a single dorsal root ganglion (DRG) attenuated neuroglial activity at the corresponding spinal dorsal horn. Recently, caudal epidural PRF has been used to manage neuropathic pain, but evidence of molecular changes after the administration of caudal epidural PRF to attenuate neuropathic pain is lacking, and it has not been determined whether caudal epidural PRF affects neuroglial activity at different spinal levels. Objectives: Using immunohistochemical methods in a rat model of lumbar disc herniation, the authors investigated the effects of caudal epidural PRF administration on pain-related behavior, on the activations of microglia and astrocytes in spinal cord, and on the expressions of calcitonin gene-related peptide (CGRP) and Transient receptor potential vanilloid 1(TRPV1) in the DRG at the L3, L4, L5, L6, and S1 levels. Study Design: Controlled animal trial. Setting: University hospital laboratory. Methods: Forty-five Sprague-Dawley rats were randomly assigned to a sham-operated group (n = 10) or a nucleus pulposus (NP)-exposed group (n = 35). Rats in the NP-exposed group were further subdivided into a NP-exposed with sham stimulation group (the NP-nonPRF group; n = 13) or a NP exposed with caudal epidural PRF stimulation group (the NP-PRF group; n = 22). Pulsed radiofrequency was administered on postoperative day 10 (POD 10) by placing an electrode in the caudal epidural space through the sacral hiatus and administering 5 Hz of PRF current for 600 seconds (maximum tip temperature 42°C). Rats were tested for mechanical allodynia on POD 10 and on days 7 and 14 after caudal epidural PRF administration (post-PRF). At 14 days post-PRF, sections of the spinal cord from L3, L4, L5, L6, and S1 were immunostained for ionized calciumbinding adapter molecule 1 (Iba1) and glial fibrillary acidic protein (GFAP), and DRGs from the same levels were immunostained for CGRP and TRPV1. Results: Mechanical withdrawal thresholds increased at 7 days post-PRF (P = 0.04), and the immunohistochemical expression of Iba1 in the L5 spinal dorsal horn and of CGRP in the L5 DRG were quantitatively reduced (P < 0.001) at 14 days post-PRF. Furthermore, the upregulations of Iba1 at L3, L4, L6, and S1 dorsal horns and CGRP at L6 DRG were also attenuated by caudal epidural PRF (P < 0.001). Limitation: We examined molecular changes only in ipsilateral lumbar regions and at 14 days post-PRF. Conclusion: Caudal epidural PRF reduced mechanical allodynia and downregulated microglia activity and CGRP expression at the lumbar disc herniated level and in adjacent lumbar spinal levels in a rat model of lumbar disc herniation. Key words: Caudal, pulsed radiofrequency, multisegmental, lumbar disc herniation, microglia, calcitonin gene-related peptide

Since the percutaneous posterolateral approach in treating lumbar disc herniation was introduced in 1973, percutaneous endoscopic lumbar discectomy (PELD) has become a routine minimally invasive spinal procedure. However, as clinical evidence accumulated, several complications of PELD have raised our concerns, including the intraoperative injury to neural, vascular structures and failure of surgery. Herein, we present 2 patients who experienced guidewire breakage during PELD procedure to demonstrate the details. The 2 patients, who are 28 and 33 years old, were diagnosed with lumbar disc herniation with or without intervertebral foreman stenosis by magnetic resonance imaging. Following a preoperative evaluation, a PELD procedure was performed with the help of local anesthesia. During the advancement of the obturator and foraminotomy under fluoroscopy, the guidewire was found broken. With the patients’ permission, the operator inserted the working cannula to the broken end of the guidewire and retrieved it by straight grasping forceps under endoscopy. The patients were reported to recover from their back pain immediately after the operation and hence the postoperative course was stable. In conclusion, the guidewire breakage in PELD procedures is a rare but severe complication, which requires immediate removal. An appropriate manner and fluoroscopic control are recommended to forestall such problems. It is possible to retrieve the broken guidewire under endoscopy with skillful experience. Key words: Endoscopic discectomy, intraoperative complication, instrument breakage, minimally invasive surgery