182 Posterior Micro-Endoscopic Discectomy vs. ACDF for Single-level Radiculopathy: Comparative Effectiveness and Cost-Utility Analysis

Neurosurgery ◽  
2017 ◽  
Vol 64 (CN_suppl_1) ◽  
pp. 248-248 ◽  
Author(s):  
Matthew J McGirt ◽  
E Hunter Dyer ◽  
Domagoj Coric ◽  
Silky Chotai ◽  
Anthony L Asher ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Indirect Cost ◽  
Disc Herniation ◽  
Comparative Effectiveness ◽  
Cervical Radiculopathy ◽  
Foraminal Stenosis ◽  
Single Level ◽  
Estimated Blood Loss ◽  
Endoscopic Discectomy ◽  
One Year

Abstract INTRODUCTION Cervical radiculopathy remains highly prevalent and costly in the U.S. healthcare system. While ACDF has remained the most popular surgical treatment modality, minimally invasive advancements such as posterior micro-endoscopic discectomy/foraminotomy (pMED) has emerged as a motion preserving and less invasive alternative. To date, the comparative effectiveness and cost-effectiveness of pMED vs. ACDF remains unclear. METHODS Patients undergoing surgery for single-level radiculopathy without myelopathy resulting from foraminal stenosis or foraminal disc herniation without instability over a one-year period were prospectively enrolled into an institutional database. Baseline, post -operative 3-months, and 12-months VAS-Arm and Neck, NDI, EQ −5D, and return to work(RTW) status were collected. Direct healthcare cost(payer perspective) and indirect cost (work-day losses multiplied by median gross-of-tax wage and benefits rate) was assessed. RESULTS >Total 20 ACDF and 28 pMED patients were identified. Baseline demographics, symptomatology, and co-morbidities were similar between the cohorts. For pMED vs. ACDF, mean length of surgery (48.1 ± 20.0 vs. 69.9 ± 11.6 minutes, P < 0.0001) and estimated blood loss (20.3 ± 9.3 vs. 31.8 ± 15.4 mL, P = 0.04) was reduced. There was no 90-day morbidity or re-admission for either cohort. One(3.6%) pMED patient required a subsequent ACDF; no patients in the ACDF cohort required re-operation by one-year. pMED and ACDF cohorts demonstrated similar improvement in arm-VAS(3.1 vs. 2.6, P = 0.66), neck-VAS(2.0 vs. 3.2, P = 0.24), NDI(9.0 vs. 6.8, P = 0.24), and EQ-5D(0.17 vs. 0.15, P = 0.82). Ability to RTW(93.8% vs. 94.1%, P = 1.0) and median time to RTW(3.7[0.9- 8.1] vs. 3.6[2.1-8.5] weeks, P = 0.85) were similar. pMED was associated with significantly reduced direct cost (p>0.001) but similar indirect cost (P = 0.43), resulting in an average total cost savings of $7689(P < 0.01) per case with similar QALY-gain (0.17 vs. 0.15, P = 0.82). CONCLUSION For single-level unilateral-radiculopathy resulting from foraminal stenosis or lateral disc herniation without segmental instability, pMED was equivalent to ACDF in safety and effectiveness. pMED represents a minimally invasive, motion preserving alternative to select patients with cervical radiculopathy without the need for implant costs with concomitant significant cost saving.

The impact of minimally invasive cervical spine surgery

2004 ◽  
Vol 1 (1) ◽  
pp. 43-46 ◽  
Author(s):  
Tim E. Adamson
Keyword(s):  
Cervical Spine ◽  
Surgical Technique ◽  
Minimally Invasive ◽  
Cervical Radiculopathy ◽  
Foraminal Stenosis ◽  
Content Type ◽  
Cervical Spine Surgery ◽  
The Impact ◽  
Safe Treatment Option ◽  
Fine Print

✓ Since 1997, cervical endoscopic laminoforaminotomy (CELF) has been an effective and safe treatment option for unilateral cervical radiculopathy secondary to disc herniation or foraminal stenosis. The development of the surgical technique is reviewed and recent outcomes discussed. Its impact is addressed in relation to the patient and surgeon.

scholarly journals Perioperative outcomes and adverse events of minimally invasive versus open posterior lumbar fusion: meta-analysis and systematic review

2016 ◽  
Vol 24 (3) ◽  
pp. 416-427 ◽  
Author(s):  
Christina L. Goldstein ◽  
Kevin Macwan ◽  
Kala Sundararajan ◽  
Y. Raja Rampersaud
Keyword(s):  
Systematic Review ◽  
Adverse Event ◽  
Adverse Events ◽  
Minimally Invasive ◽  
Comparative Effectiveness ◽  
Meta Analysis ◽  
Perioperative Outcomes ◽  
Estimated Blood Loss ◽  
Significant Difference ◽  
Patient Reported

OBJECT The objective of this study was to determine the clinical comparative effectiveness and adverse event rates of posterior minimally invasive surgery (MIS) compared with open transforaminal or posterior lumbar interbody fusion (TLIF/PLIF). METHODS A systematic review of the Medline, EMBASE, PubMed, Web of Science, and Cochrane databases was performed. A hand search of reference lists was conducted. Studies were reviewed by 2 independent assessors to identify randomized controlled trials (RCTs) or comparative cohort studies including at least 10 patients undergoing MIS or open TLIF/PLIF for degenerative lumbar spinal disorders and reporting at least 1 of the following: clinical outcome measure, perioperative clinical or process measure, radiographic outcome, or adverse events. Study quality was assessed using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) protocol. When appropriate, a meta-analysis of outcomes data was conducted. RESULTS The systematic review and reference list search identified 3301 articles, with 26 meeting study inclusion criteria. All studies, including 1 RCT, were of low or very low quality. No significant difference regarding age, sex, surgical levels, or diagnosis was identified between the 2 cohorts (856 patients in the MIS cohort, 806 patients in the open cohort). The meta-analysis revealed changes in the perioperative outcomes of mean estimated blood loss, time to ambulation, and length of stay favoring an MIS approach by 260 ml (p < 0.00001), 3.5 days (p = 0.0006), and 2.9 days (p < 0.00001), respectively. Operative time was not significantly different between the surgical techniques (p = 0.78). There was no significant difference in surgical adverse events (p = 0.97), but MIS cases were significantly less likely to experience medical adverse events (risk ratio [MIS vs open] = 0.39, 95% confidence interval 0.23–0.69, p = 0.001). No difference in nonunion (p = 0.97) or reoperation rates (p = 0.97) was observed. Mean Oswestry Disability Index scores were slightly better in the patients undergoing MIS (n = 346) versus open TLIF/PLIF (n = 346) at a median follow-up time of 24 months (mean difference [MIS – open] = 3.32, p = 0.001). CONCLUSIONS The result of this quantitative systematic review of clinical comparative effectiveness research examining MIS versus open TLIF/PLIF for degenerative lumbar pathology suggests equipoise in patient-reported clinical outcomes. Furthermore, a meta-analysis of adverse event data suggests equivalent rates of surgical complications with lower rates of medical complications in patients undergoing minimally invasive TLIF/PLIF compared with open surgery. The quality of the current comparative evidence is low to very low, with significant inherent bias.

Percutaneous Full Endoscopic Posterior Decompression for Revision of Lumbar Spinal Dynamic Stabilization

2021 ◽  
Author(s):  
Changkun Zheng ◽  
Zhong Liao ◽  
Weiliang cui
Keyword(s):  
Disc Herniation ◽  
Outcome Data ◽  
Dynamic Stabilization ◽  
Endoscopic Approach ◽  
Leg Pain ◽  
Foraminal Stenosis ◽  
Posterior Decompression ◽  
Endoscopic Discectomy ◽  
Poor Outcomes ◽  
Lumbar Spinal

Abstract Objective: The objective of this article was to analysis the efficacy of percutaneous full endoscopic posterior decompression for revision of lumbar spinal dynamic stabilization.Methods: Twenty consecutive patients with failed lumbar spinal dynamic stabilization presenting with leg pain that had supporting imaging diagnosis of lateral stenosis and /or residual / recurrent disc herniation, or whose pain complaint was supported by relief from diagnostic and therapeutic injections, were offered percutaneous transforaminal endoscopic discectomy and foraminoplasty over a repeat open procedure. Each patient sought consultation following a transient successful, partially successful or unsuccessful open lumbar spinal dynamic stabilization surgery for disc herniation or spinal stenosis. Endoscopic foraminoplasty was also performed to either decompress the bony foramen for foraminal stenosis, or foraminoplasty to allow for endoscopic visual examination of the affected traversing and exiting nerve roots in the axilla. The average follow up time was, average 37.9 months, minimum 24 months. Outcome data at each visit included Macnab, VAS and ODI.Results: The average leg Visual Analog Scale improved from 8.9 ± 2.6 to 1.08± 0.7 (p < 0.005). Fifteen patients had excellent outcomes, four had good outcomes, one had fair outcomes, and no had poor outcomes, according to the Macnab criteria (Table 2). Nineteen of 20 patients had excellent or good outcomes, for an overall success rate of 95%. No patients required reoperation. There were no incidental durotomies, infections, vascular or visceral injuries. They were also relieved to be able to avoid "open" decompression.Conclusion: The transforaminal endoscopic approach is effective for failed lumbar spinal dynamic stabilization surgery due to residual/recurrent nucleus pulposus and lateral stenosis. Failed initial index surgery may involve failure to recognize patho-anatomy in the axilla of the foramen housing the traversing and the exiting nerve. The transforaminal endoscopic approach effectively decompresses the foramen and does not further destabilize the spine needing stabilization. It also avoids going through the previous surgical site.

scholarly journals Single-level anterior cervical discectomy and fusion versus minimally invasive posterior cervical foraminotomy for patients with cervical radiculopathy: a cost analysis

2014 ◽  
Vol 37 (5) ◽  
pp. E9 ◽  
Author(s):  
Haley E. Mansfield ◽  
W. Jeffrey Canar ◽  
Carter S. Gerard ◽  
John E. O'Toole
Keyword(s):  
Minimally Invasive ◽  
Smoking Status ◽  
Cervical Radiculopathy ◽  
Direct Costs ◽  
Total Direct Cost ◽  
Single Level ◽  
Posterior Cervical Foraminotomy ◽  
The Mean ◽  
The Cost ◽  
Cervical Foraminotomy

Object Patients suffering from cervical radiculopathy in whom a course of nonoperative treatment has failed are often candidates for a single-level anterior cervical discectomy and fusion (ACDF) or posterior cervical foraminotomy (PCF). The objective of this analysis was to identify any significant cost differences between these surgical methods by comparing direct costs to the hospital. Furthermore, patient-specific characteristics were also considered for their effect on component costs. Methods After obtaining approval from the medical center institutional review board, the authors conducted a retrospective cross-sectional comparative cohort study, with a sample of 101 patients diagnosed with cervical radiculopathy and who underwent an initial single-level ACDF or minimally invasive PCF during a 3-year period. Using these data, bivariate analyses were conducted to determine significant differences in direct total procedure and component costs between surgical techniques. Factorial ANOVAs were also conducted to determine any relationship between patient sex and smoking status to the component costs per surgery. Results The mean total direct cost for an ACDF was $8192, and the mean total direct cost for a PCF was $4320. There were significant differences in the cost components for direct costs and operating room supply costs. It was found that there was no statistically significant difference in component costs with regard to patient sex or smoking status. Conclusions In the management of single-level cervical radiculopathy, the present analysis has revealed that the average cost of an ACDF is 89% more than a PCF. This increased cost is largely due to the cost of surgical implants. These results do not appear to be dependent on patient sex or smoking status. When combined with results from previous studies highlighting the comparable patient outcomes for either procedure, the authors' findings suggest that from a health care economics standpoint, physicians should consider a minimally invasive PCF in the treatment of cervical radiculopathy.

Differences between soft-disc herniation and spondylosis in cervical arthroplasty: CT-documented heterotopic ossification with minimum 2 years of follow-up

2012 ◽  
Vol 16 (2) ◽  
pp. 163-171 ◽  
Author(s):  
Jau-Ching Wu ◽  
Wen-Cheng Huang ◽  
Tsung-Hsi Tu ◽  
Hsiao-Wen Tsai ◽  
Chin-Chu Ko ◽  
...  
Keyword(s):  
Heterotopic Ossification ◽  
Clinical Outcomes ◽  
Disc Herniation ◽  
Cervical Disc ◽  
Artificial Disc ◽  
Cervical Arthroplasty ◽  
Single Level ◽  
Arm Pain ◽  
Estimated Blood Loss

Object Cervical arthroplasty is a valid option for patients with single-level symptomatic cervical disc diseases causing neural tissue compression, but postoperative heterotopic ossification (HO) can limit the mobility of an artificial disc. In the present study the authors used CT scanning to assess HO formation, and they investigated differences in radiological and clinical outcomes in patients with either a soft-disc herniation or spondylosis who underwent cervical arthroplasty. Methods Medical records, radiographs, and clinical evaluations of consecutive patients who underwent single-level cervical arthroplasty were reviewed. Arthroplasty was performed using the Bryan disc. The patients were divided into a soft-disc herniation group and a spondylosis group. Clinical outcomes were measured using the visual analog scale (VAS) for neck and arm pain and the Neck Disability Index (NDI), whereas HO grading was determined by studying CT scans. Radiological and clinical outcomes were analyzed, and the minimum follow-up duration was 24 months. Results Forty-seven consecutive patients underwent a single-level cervical arthroplasty. Forty patients (85.1%) had complete radiological evaluations and clinical follow-up of more than 2 years. Patients were divided into 1 of 2 groups: soft-disc herniation (16 cases) and the spondylosis group (24 cases). Their mean age was 45.51 ± 11.12 years. Sixteen patients (40%) were female. Patients in the soft-disc herniation group were younger than those in the spondylosis group, but the difference was not statistically significant (42.88 vs 47.26, p = 0.227). The mean follow-up duration was 38.83 ± 9.74 months. Sex, estimated blood loss, implant size, and perioperative NSAID prescription were not significantly different between the groups (p = 0.792, 0.267, 0.581, and 1.000, respectively). The soft-disc herniation group had significantly less HO formation than the spondylosis group (1 HO [6.25%] vs 14 Hos [58.33%], p = 0.001). Almost all artificial discs in both groups remained mobile (100% and 95.8%, p = 0.408). The clinical outcomes were not significantly different between the groups at all postoperative time points of evaluation, and clinical improvements were also similar. Conclusions Clinical outcomes of single-level cervical arthroplasty for soft-disc herniation and spondylosis were similar 3 years after surgery. There was a significantly higher rate of HO formation in patients with spondylosis than in those with a soft-disc herniation. The mobility of the artificial disc is maintained, but the long-term effects of HO and its higher frequency in spondylotic cases warrant further investigation.

scholarly journals Endoscopic Retrieval of a Broken Guidewire During Spinal Surgery

2016 ◽  
Vol 19 (2;2) ◽  
pp. E339-E342 ◽  
Author(s):  
Xin Gu
Keyword(s):  
Minimally Invasive ◽  
Lumbar Disc Herniation ◽  
Disc Herniation ◽  
Lumbar Disc ◽  
Preoperative Evaluation ◽  
Posterolateral Approach ◽  
Intraoperative Complication ◽  
Endoscopic Discectomy ◽  
Endoscopic Retrieval ◽  
Endoscopic Lumbar Discectomy

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

scholarly journals Transforaminal Endoscopic Treatment of Lumbar Radiculopathy after Instrumented Lumbar Spine Fusion

2015 ◽  
Vol 2;18 (2;3) ◽  
pp. 179-184
Author(s):  
Albert E. Telfeian
Keyword(s):  
Retrospective Study ◽  
Minimally Invasive ◽  
Lumbar Fusion ◽  
Herniated Disc ◽  
Invasive Technique ◽  
Lumbar Radiculopathy ◽  
Vas Score ◽  
Constant Pain ◽  
Endoscopic Discectomy ◽  
One Year

Background: Transforaminal endoscopic discectomy and foraminotomy is a well-described minimally invasive technique for surgically treating lumbar radiculopathy caused by a herniated disc and foraminal narrowing. Objective: To describe the technique and feasibility of transforaminal foraminoplasty for the treatment of lumbar radiculopathy in patients who have already undergone instrumented spinal fusion. Study Design: Retrospective study. Setting: Hospital and ambulatory surgery center Methods: After Institutional Review Board approval, charts from 18 consecutive patients with lumbar radiculopathy and instrumented spinal fusions who underwent endoscopic procedures between 2008 and 2013 were reviewed. Results: The average pain relief one year postoperatively was reported to be 67.0%, good results as defined by MacNab. The average preoperative VAS score was 9.14, indicated in our questionnaire as severe and constant pain. The average one year postoperative VAS score was 3.00, indicated in our questionnaire as mild and intermittent pain. Limitations: This is a retrospective study and only offers one year follow-up data for patients with instrumented fusions who have undergone endoscopic spine surgery. Conclusion: Transforaminal endoscopic discectomy and foraminotomy could be used as a safe, yet, minimally invasive and innovative technique for the treatment of lumbar radiculopathy in the setting of previous instrumented lumbar fusion. IRB approval: Meridian Health: IRB Study # 201206071J Key words: Endoscopic siscectomy, minimally-invasive, transforaminal, fusion

scholarly journals Evaluation of the effectiveness of surgical methods for the treatment of recurrent lumbar disc herniation: a cohort retrospective study

2021 ◽  
Vol 18 (2) ◽  
pp. 34-43
Author(s):  
M. N. Kravtsov ◽  
I. A. Kruglov ◽  
S. D. Mirzametov ◽  
A. S. Seleznev ◽  
N. P. Alekseyeva ◽  
...  
Keyword(s):  
Intervertebral Disc ◽  
Lumbar Disc Herniation ◽  
Disc Herniation ◽  
Interbody Fusion ◽  
Lumbar Disc ◽  
Disc Replacement ◽  
Single Level ◽  
Surgical Methods ◽  
Endoscopic Discectomy ◽  
Recurrent Lumbar Disc Herniation

Objective. To compare the effectiveness of surgical methods for treating patients with recurrent lumbar disc herniation.Material and Methods. The sample consisted of 160 patients operated on in 2014–2019 for recurrent lumbar disc herniation by percutaneous endoscopic discectomy (Group 1), microsurgical discectomy (Group 2), single-level transforaminal interbody fusion (Group 3) and single-level total intervertebral disc replacement (Group 4). The effectiveness of surgical treatment was evaluated using the NRS-11, ODI, and MacNab questionnaires.Results. Assessment of the pain syndrome severity and the vital activity level of patients revealed significant (p < 0.05) differences in favor of total intervertebral disc replacement. Excellent and good outcomes after arthroplasty according to MacNab criteria were noted in all patients in this group. Similar outcomes were reported in 77.5 % (31/40) of patients in the TLIF group, in 75.1 % (24/32) of patients in the percutaneous endoscopic discectomy group and in 72.6 % (45/62) of patients in the microdiscectomy group. The operation time and length of hospital stay were shorter in the endoscopic and microsurgical discectomy groups (p < 0.001). However, the lower incidence of complications and reoperations was observed in groups of posterior interbody fusion and arthroplasty (p > 0.05).Conclusion. Arthroplasty with the M6-L implant expands the possibilities of surgery for recurrent lumbar disc herniation. Total intervertebral disc replacement and posterior interbody fusion for recurrent lumbar disc herniation are more effective in comparison with decompressive operations, which is reflected in the improvement of clinical treatment outcomes, reduction of perioperative complications and frequency of repeated interventions.

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