Analysis of the Results of Surgical Treatment
of Herniated Intervertebral Discs in the Lumbar
Spine using Endoscopic Microdiscectomy and Standard
Sh Sh Shatursunov1, Shomansur Sh Shatursunov1*, S A Mirzakhonov1, D I Eshkulov1 and Kh A Abdusattarov2
1Republican Specialized Scientific and Practical Medical Center of Traumatology and Orthopedics, Tashkent, Uzbekistan
2Tashkent Medical Academy, Tashkent, Uzbekistan
Submission: April 05, 2023; Published: May 09, 2023
*Corresponding author: Shomansur Sh Shatursunov, Republican Specialized Scientific and Practical Medical Center of Traumatology and Orthopedics, Tashkent, Uzbekistan
How to cite this article: Sh Sh Shatursunov, Shomansur Sh Shatursunov, S A Mirzakhonov, D I Eshkulov, Kh A A. Analysis of the Results of Surgical
Treatment of Herniated Intervertebral Discs in the Lumbar Spine using Endoscopic Microdiscectomy and Standard Microdiscectomy. J Head Neck Spine
Surg. 2023; 4(5): 555649. DOI: 10.19080/JHNSS.2023.04.555649
The results of percutaneous endoscopic and microsurgical discectomy are compared. It was found that the time of surgery, significant bed-days and the period of disability were associated with the group of endoscopic microdiscectomy. The rates of complications and re-arrests as a result of detention were found. The risk of recurrence was 5.4% for the endoscopic group, 5.8% for the microsurgical group. Significant differences in terms of local and radicular pain, quality of life and the physical component of health were not established. The mental health component was the best in the endoscopic group. Good and excellent results according to the Macnub treatment satisfaction scale in the endoscopy group were noted in 88.2% of cases, after microdiscectomy - in 74.9%. Less invasiveness of percutaneous endoscopy was reflected in the reduction of the period of hospitalization and disability. There was a statistically insignificant increase in the risk of hernia recurrence after percutaneous endoscopic discectomy. Indicators of infectious complications in the form of spondylodiscitis and epiduritis were typical for standard microdiscectomy.
Keywords: Herniated Disc; Discogenic Radiculopathy; Lumbar Discectomy; Endoscopic Microdiscectomy; Standard Microdiscectomy; Recurrence of Herniated Disc
According to modern literary sources, about 80% of people during their lives suffered at least one episode of low back pain with or without pain in the lower extremities [1,2]. Up to 70% of people at least once in their lives experienced such back pain that made them turn to a neurologist, and 19% of those who applied were forced to resort to surgery due to the lack of a tangible effect from conservative therapy [2,3]. In 5-10% of patients, low back pain is caused by herniated intervertebral discs and is accompanied by radiculopathy and sciatica in 43% of cases . The number of patients with a herniated disc is increasing all over the world, including at the expense of young people. Currently, one
of the most effective and at the same time relatively safe methods of treatment of intervertebral hernia of the lumbosacral spine is its endoscopic removal [1,4].
There are several stages in the evolution of endoscopic technologies in medicine, each of which is characterized by the improvement of equipment and the emergence of new diagnostic and treatment methods: fiber optic (1958–1981), digital (1981–2003) and the modern stage of telemedicine technologies. Leaving aside the first attempts at intravital endoscopy of the epidural and subarachnoid spaces of the human spinal cord, undertaken by Pool in 1937, the beginning of the introduction of endoscopic methods of treating spinal diseases into clinical practice should
be considered the 80s. XX century., attributable to the digital
period of endoscopy. By that time, modern models of rigid and
flexible endoscopes had already been designed, and they were
tested in various fields of surgery. Thanks to this, a high level of
diagnostic and therapeutic endoscopic interventions on the spine
was achieved by the efforts of neurosurgeons and orthopedists in
a relatively short time interval.
Percutaneous video endoscopic spine surgery currently
includes operations performed from percutaneous access under
the control of radiation and video endoscopic imaging methods,
using rigid multichannel endoscopes and special instruments. Such
a combination of interventional and video endoscopic technologies
in spinal surgery is referred to in the English-language literature
as a full-endoscopy method (literally - “completely endoscopic”).
In the 1990s, a technique was developed that made it possible to
use endoscopic discectomy and endoscopic posterior interbody
fusion; An original port for interlaminar access was developed and
introduced into clinical practice. At the same time, the principles
of endoscopic decompression were developed for the treatment
of degenerative spinal stenosis . Thus, endoscopic methods
for removing intervertebral hernias using the interlaminar PSLD
(Percutaneous Stenoscopic Lumbar Decompression) method
have been introduced into surgical practice. PSLD has the features
and benefits of minimally invasive treatment, including a small
incision, little blood loss, atraumaticity, and, as a result, early
rehabilitation. PSLD does not disrupt the structure of the spinal
canal, does not affect the stability of the spine, and does not lead to
significant postoperative fibrosis in the spinal canal [6-8].
The popularization of this technique has accelerated
technical progress in this field of medicine. The possibilities of
percutaneous endoscopic surgery have increased significantly [9-
11]. Access to the spinal canal is no longer absolutely dependent
on the presence of interosseous spaces of the spine and their size.
In terms of the surgical accessibility of herniated intervertebral
discs, percutaneous endoscopy with all the approaches and
techniques available to the neurosurgeon is not inferior to
standard microdiscectomy (Figure 1). Despite the prevalence of
the technique, it remains unclear to this day whether endoscopic
microdiscectomy will become the new standard of surgical
treatment for discogenic lumboischialgia, while displacing
lumbar microdiscectomy. In terms of the surgical accessibility of
herniated intervertebral discs, percutaneous endoscopy with all
the approaches and techniques available to the neurosurgeon is
not inferior to standard microdiscectomy. Despite the prevalence
of the technique, it remains unclear to this day whether endoscopic
microdiscectomy will become the new standard of surgical
treatment for discogenic lumboischialgia, while displacing lumbar
microdiscectomy. The final answer- to this question will probably
be obtained in the course of randomized controlled trials of clinical
efficacy, taking into account all options for the use of intracanal
endoscopic approaches and techniques. In connection with the
above, there is a need for further comparative prospective studies
of microdiscectomy (MD) and endoscopic microdiscectomy
(EMD), which was undertaken in this work [12,13] (Figure 1).
A prospective non-randomized study of 156 patients with
herniated lumbar intervertebral discs operated in the clinic of
vertebrology of the Republican Specialized Scientific and Practical
Medical Center of Traumatology and Orthopedics of the Ministry
of Health of the Republic of Uzbekistan for the period from 2020
to 2023 was carried out. The study included patients aged 20
to 76 years who had lumboischialgia due to herniated lumbar
intervertebral disc hernia. All patients underwent a comprehensive
neurological and instrumental examination, including traditional
and functional radiography of the lumbosacral spine, MSCT (CT)
and MRI, as well as electroneuromyography (ENMG).
The criteria for selecting patients for the study were the
ineffectiveness of conservative therapy for more than 3 months,
frequent recurrences of pain (more than 3 times a year), the
presence of neurological symptoms in the lower extremities, MRI
or CT verification of a herniated disc at the level of L3-L4, L4-
L5 or L5–S1, as well as electroneuromyography confirmation of
root compression. The study did not include patients operated
on for repeated disc herniation, who had more than one level of
lesions, degenerative spinal canal stenosis, instability of the spinal
segments, as well as patients with severe concomitant somatic
pathology. The inclusion of patients in one of the groups was
carried out in accordance with the technique of the performed
operation. The first group consisted of patients operated on by
microsurgical discectomy (n = 64), the second - patients who
underwent endoscopic discectomy using the PSLD (Percutaneous
Stenoscopic Lumbar Decompression) technique (n = 92). All
patients were operated on by the same surgical team. Each
technique used a standard set of instruments. The choice of the
surgical technique was based on the preference of the patient
and the availability of the necessary equipment at the time of the
operation. Patients became more active on the first-fourth day
after the operation and observed the orthopedic regimen for a
month after the operation.
A comparative analysis of the outcome was performed on the
basis of self-assessment of the functional state according to the
Oswestry quality of life scale 3 and 6 months after the operation.
The following indicators were also assessed: the severity of the
pain syndrome according to the 100-mm visual analog pain scale
(VAS), the subjective outcome of the treatment according to the
Macnub criterion . Statistical processing was carried out using
the Statistica 8.0 program (StatSoft Inc.). The statistical significance
of the differences was established for repeated measurements (3
and 6 months after the operation).
Operations were performed under spinal or general anesthesia.
The thoracic-knee position was used to reduce intraoperative
bleeding from epidural veins , as well as to reduce the necessary
resection of bone structures during access due to the positional
increase in the interlaminar gap. The first stage of the operation
is fluoroscopic control of the level of intervention using an image
intensifier tube (electronic-optical converter-EOC) (Figure 2).
It is very important to position the needle strictly perpendicular
to the patient’s skin, so we get a clear vector, relative to which we
plan the skin incision. With the help of an image intensifier tube,
the needle is placed in the direction of the desired intervertebral
disc. After determining the access level, the position of the
intervertebral disc relative to the specified access trajectory
is noted on the x-ray. If, at the same time, the vertebral arch is
visualized on the access trajectory, it is advisable to shift the
incision center somewhat caudally, for better visualization of
the ligament flavum and ease of work in the interlaminar space.
We also consider it necessary at this stage to assess the location
of the herniated disc in relation to the bone structures that will
be in the area of access (intervertebral joint, pedicle, edge of the
underlying vertebral body). The next step is an incision in the skin
and subcutaneous tissue 0.5 cm lateral to the midline. Next, the
aponeurosis of the muscles that straighten the spine is opened
with a linear incision and dilators are installed, which form access
through the muscles for the working port (Figure 3).
From this point on, manipulations are performed under
endoscopic control. The interlaminar gap is freed from fiber and
soft tissues, then the yellow ligament is opened. We recommend
blunt opening of the ligamentum flavum due to the lack of threedimensionality
of the endoscopic picture and the high probability
of damage to the dura when opening the ligamentum flavum with
a sharp instrument. After partial resection of the ligamentum
flavum, we consider it most appropriate to visualize the origin of
the spinal nerve (Figure 4
After the nerve is displaced medially, a herniated disc is
isolated. Particular attention at this stage of the operation should
be given to hemostasis, since the aggressive removal of a herniated
disc usually causes damage to the ventrally located veins, which
significantly complicates further manipulations in the narrow
space of endoscopic access. Opening and removal of a herniated
disc is not the last stage of the operation. It is necessary to open
the posterior longitudinal ligament, inspect the ventral surface
of the dural sac, using the possibility of rotating the endoscope
and changing the angle of the port. Next, free fragments of the
intervertebral disc are removed and excessive hydraulic pressure
is created in the disc cavity to check the completeness of the
hernia removal and prevent the development of acute recurrence.
As a final step, we always perform an economical foraminotomy to
increase the reserve space for the spinal nerve.
The neurological status of patients before surgery varied
according to the intensity of the radicular pain syndrome and
the duration of the disease. Immediately after the operation,
the majority of patients experienced a complete regression of
radicular pain syndrome, and all patients were subjected to the
same activity restrictions - restriction of axial loads and strictly
mandatory wearing of an orthopedic lumbar corset for 1 month
after the intervention. Of the 92 patients in the endoscopic group,
5 (5.4%) had a relapse, which required a second operation. In 4
(3.4%) patients, prolonged pain was observed within 1 month
after discharge, which corresponded to an unsatisfactory result
on the Macnub scale. In 7 (7.6%) patients, short-term pain of a
pulling nature was observed for no more than 1 week after surgery.
Another 6 (6.5%) patients had short-term sensations, qualified
by patients as aching pain in the same dermatome as before the
operation, but regressed on the 1st–2nd day after the operation.
The remaining patients noted the complete disappearance of all
symptoms and returned to normal life soon after discharge. Thus,
the efficiency of the endoscopic method was 88.2%. In group 1
of patients, where standard microdiscectomy was performed,
excellent and good results occurred in 74.9% of cases.
The frequency of complications - damage to the dura mater,
spondylodiscitis and damage to the roots was 3.2%, the frequency
of reoperations for recurrent disc herniation was 5.8%. In the
process of performing the work, an analysis was made of the
technical characteristics and use of the endoscopic discectomy
method in comparison with the microsurgical method. It is noted
that with the endoscopic method it is possible to use standard
microsurgical instruments; due to the technical possibility of
rotating the endoscope around the port, a more efficient use of the
access space during endoscopic interventions has been achieved.
Analysis of the results of removal of herniated intervertebral discs
by the portal endoscopic method 6 months after the operation
showed that portal endoscopic techniques are highly effective and
less traumatic. According to our data, the efficiency of endoscopic
microdiscectomy in the removal of herniated intervertebral discs
is 95.9%, while in microsurgical discectomy it is 85.5%.
The most significant complication of both types of operations
was the recurrence of herniated intervertebral discs. In the 1st
group of patients, relapse was in 5.8% of cases, and in the 2nd
group - in 5.4%. Similar results may be associated with more
significant aggression during surgery and destabilization of the
segment in the postoperative period with subsequent development
of recurrent disc herniation in the operated segment. In 1.1%
of cases with endoscopic microdiscectomy, damage to the dura
mater was noted, which did not lead to any symptoms.
An analysis of the technical capabilities of endoscopic
microdiscectomy showed the possibility of using all standard
microsurgical instruments during the operation without impairing
the visibility of the surgical intervention area. When applying this
method, the space created during the access is used much more
efficiently. Given the less traumatic approach and the effective
use of a plasma coagulator, less pronounced bleeding was noted
throughout the operation.
Based on the study, we can say that the efficiency of endoscopic
discectomy is comparable to the microsurgical technique.
Considering that this method is comparable to microdiscectomy
in terms of its technical characteristics and capabilities, this
technology can be used to remove herniated intervertebral discs.
In some cases, the technical capabilities of the method allow
decompression of nerve structures, which can be used in the
treatment of non-discogenic spinal canal stenoses.
Wang H, Song Y, Cai L (2017) Effect of percutaneous transforaminal lumbar spine endoscopic discectomy on lumbar disc herniation and its influence on indexes of oxidative stress. Biomedical Research 28(21): 9464-9469.
Zorin NA (2014) Comparative assessment of the effectiveness of endoscopic transforaminal microdiscectomy and open microdiscectomy in the treatment of herniated intervertebral discs of the lumbar spine. Ukr Neurochir Journ 3: 61-65.