Selective Retention of Bone Marrow Stromal Cells with Gelatin Sponge for Repair of Intervertebral Disc Defects after Microendoscopic Discectomy: A Prospective Controlled Study and 2-Year Follow-Up

Objective. Discectomy remains the classic procedure for treating lumbar intervertebral disc (IVD) herniation, but the occurrence of defects after discectomy is thought to be an important cause generating recurrent and accelerated IVD degeneration. Previous studies attempted suture of the annulus fissure, but the validity of this technique on restraining the degenerative process is controversial. On the other hand, cell therapies have been shown in multiple clinical and basic studies. Our purpose was to investigate the effectiveness of selective retention of autologous Bone Marrow Stromal Cells (BMSCs) with gelatin sponge in combination with annulus fibrosus suture (AFS) for the repair of IVD defects following mobile microendoscopic discectomy (MMED). Methods. This prospective, two-armed, and controlled clinical study was conducted from December 2016 to December 2018. Written informed consent was obtained from each patient. Forty-five patients with typical symptoms, positive signs of radiculopathy, and obvious lumbar disc herniation observed by MRI were enrolled. Patients were divided into 3 groups with different treating methods: MMED ( n = 15 ), MMED+AFS ( n = 15 ), and MMED+AFS+BMSCs ( n = 15 ). A postoperative 2-year follow-up was performed to evaluate the patient-reported outcomes of VAS, ODI, and SF-36. The improvement rate of VAS and ODI was calculated as latest ‐ preoperative / preoperative to evaluate the therapeutic effect of the three groups. Assessment parameters included Pfirrmann grade, intervertebral disc height (IDH), and disc protrusion size (DPS), as measured by MRI to evaluate the morphological changes. Results. All patients enrolled had a postoperative follow-up at 3, 6, 12, and 24 months. VAS and ODI scores were significantly improved compared to the preoperative status in all three groups with a mean DPS reduction rate over 50%. At the final follow-up, the improvement rate of the VAS score in the MMED+AFS+BMSCs group was significantly higher than the MMED+AFS and MMED groups ( 80.1 % ± 7.6 % vs. 71.3 % ± 7.0 % vs. 70.1 % ± 7.8 % ), while ODI improvement showed a significant change ( 65.6 % ± 8.8 % vs. 59.9 % ± 5.5 % vs. 57.8 % ± 8.1 % ). All participants showed significant improvement in SF-36 PCS and MCS; the differences between each group were not significant. The mean IDH loss rate of the MMED+AFS+BMSCs group was also significantly lower than other groups ( − 17.2 % ± 1.3 % vs. − 27.6 % ± 0.7 % vs. − 29.3 % ± 2.2 % ). The Pfirrmann grade was aggravated in the MMED and MMED+AFS groups while maintained at the preoperative grade in the MMED+AFS+BMSCs group. No adverse events of cell transplantation or recurrence were found in all patients during the postoperative follow-up period. Conclusions. It is feasible and effective to repair lumbar IVD defects using SCR-enriched BMSCs with gelatin sponges, which warrants further study and development as a cell-based therapy for IVD repair.

Clinical Evaluation, Functional Outcome and Complications of MicroEndoscopic Discectomy(MED) in Single or Double Level Lumbar Disc Herniation- A Retrospective Review of 156 Patients

Introduction: Lumbar disc herniation (LDH) is one of the most common causes for low back pain and related disabilities. Surgery is indicated in patients who do not respond to the conservative measures for at least 6 weeks or symptoms are worsened. Microendoscopic discectomy (MED) is a well-accepted minimally invasive surgical technique with similar results compared to open surgery. The purpose of this study was to evaluate the clinical outcome, functional improvement and analyze complications during MED. Methods: A retrospective analysis was conducted in 156 patients who were operated for single or double level LDH using MED between 2016 and 2018. All patients were evaluated for pain and disability using visual analogue scale (VAS) and Oswestry disability index (ODI), respectively. Modified MabNab’s criteria used to evaluate overall outcome of surgery. Operation time, estimated blood loss (EBL), hospital stay and time to return back to previous activities were evaluated. Complications and revisions were noted during follow-up to analyze clinical results. Paired t-test was used to evaluate statistical difference in VAS and ODI score during follow-up. Results: All patients were followed up at 6 weeks, 3 months, 6 months, 1 year and yearly thereafter postoperatively. Average follow-up was 25.5±9.7 months and average age was 45.0±12.7 years. Average VAS scores improved significantly from preoperative 8.7±0.8 to 2.0±1.1 postoperatively (p<0.0001). Average preoperative ODI improved significantly from 53.8±6.1 to 22.6±5.1 postoperatively (p<0.0001). Both score were maintained at the final follow-up. The average time to return to previous activity level was 35.7±14.3 days. Average operation time, EBL and hospital stay were 57.6±14.6 minutes, 36.7±13.1 mL and 2.4±0.7 days, respectively. There were total 19 (12.2%) complications and 12 (7.7%) revisions in the series. Overall clinical outcome was excellent, good, fair and poor in 73.1%, 20.5%, 5.1% and 1.3% of cases using modi

Follow-up results of microendoscopic discectomy compared to day surgery using percutaneous endoscopic lumbar discectomy for the treatment of lumbar disc herniation

Background Percutaneous endoscopic lumbar discectomy (PELD) is satisfactory for hospitalized patients with lumbar disc herniation (LDH). Currently, only a few studies have reported about the day surgery patients undergoing PELD. Methods A total of 267 patients with LDH underwent PELD during day surgery and were followed up for at least 3 years. Clinical outcomes were assessed using the visual analog scale (VAS) for leg and lower back pain (VAS-B and VAS-L, respectively) and the Oswestry disability index (ODI). The radiological outcomes, such as lumbar lordosis (LL), sacral slope (SS), the disc-height ratio, and disc instability, were recorded and compared. The clinical effects between patients treated by PELD during day surgery and microendoscopic discectomy (MED) for contemporaneous hospitalized 116 patients with LDH were compared. Results Patients treated by PELD had lower blood loss and shorter hospital stay (P < 0.001) compared to those treated by MED. VAS-L, VAS-B, and ODI decreased significantly after PELD than before the operation and 3 years postoperatively. The postoperative VAS-B in the PELD group was significantly decreased than in the MED group (P = 0.001). The complications rate was 9.4% in the PELD group and 12.1% in the MED group (P = 0.471). The 1-year postoperative recurrence rate in the PELD group was much higher than that in MED group (P = 0.042). The postoperative LL and SS in the PELD group improved significantly compared to the values in the MED group (P < 0.001). According to the disc-height ratio at 3-year follow-up, a significant height loss was observed in the MED group than in the PELD group (P = 0.014). Conclusions Although the 1-year postoperative recurrence rate was relatively high, the day surgery for LDH undergoing PELD had advantages in terms of less blood loss intraoperatively, short hospital stay, efficacy for back pain, and efficiency to maintain lumbar physiological curvature.

Comparison of Percutaneous Transforaminal Endoscopic Discectomy and Microendoscopic Discectomy for the Surgical Management of Symptomatic Lumbar Disc Herniation: A Multicenter Retrospective Cohort Study with a Minimum of 2 Years’ Follow-Up

BACKGROUND: 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. OBJECTIVES: This study intended to clarify whether PTED results in better clinical outcomes compared with MED in the surgical management of single-level LDH. STUDY DESIGN: A multicenter retrospective cohort study. SETTING: This study took place in 2 spinal minimally invasive centers in Beijing, China. METHODS: 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. RESULTS: 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 (P < 0.001); 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 (P < 0.001). 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 (P > 0.05). 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 (P > 0.05). Modified MacNab criteria showed that most patients experienced excellent and good results with no significant differences between groups (P = 0.511). LIMITATION: This was a multicenter retrospective study wherein the surgeons may have introduced bias to the study. CONCLUSIONS: 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. KEY WORDS: Percutaneous transforaminal endoscopic discectomy, microendoscopic discectomy, lumbar disc herniation, VAS score, ODI score

Comparative Study between Full-Endoscopic Discectomy and Microendoscopic Discectomy for the Treatment of Lumbar Disc Herniation

Background and objectives: Lumbar disc herniation (LDH) is a common disease in the meridian of life. Although surgical discectomy is commonly used to treat LDH, there are several different strategies. We compared the outcomes of uniportal full-endoscopic discectomy (FED) with those of microendoscopic discectomy (MED) in treating LDH. Materials and Methods: FED was performed using a 4.1-mm working channel endoscope, and MED was performed using a 16-mm diameter tubular retractor and endoscope. Data of patients with LDH treated with FED (n = 39) or MED (n = 27) by the single surgeon were retrospectively reviewed. Patient background information and operative data were collected. Pre- and postoperative low back and leg pain were evaluated using the numerical rating scale (NRS) score. Pre- and postoperative disc height index (DHI) values were calculated from plain radiographs, and the disc height loss was evaluated using the ratio (DHI ratio); Results: The median (interquartile range (IQR) Q25–75) operation times for FED and MED were 42 (33–61) and 43 (33–50) minutes, respectively. The median (IQR Q25–75) pre- and postoperative NRS scores for low back pain were 5 (2–7) and 1 (0–4), respectively, for FED and 6 (3–8) and 1 (0–2), respectively, for MED. The median (IQR Q25–75) pre- and postoperative NRS scores for leg pain were 7 (5–8) and 0 (0–2), respectively, for FED and 6 (5–8) and 0 (0–2), respectively, for MED. These data were not different between the FED and MED groups. The median (IQR Q25–75) DHI ratios of FED and MED were 0.94 (0.89–1.03) and 0.90 (0.79–0.95), respectively. The DHI ratio was significantly higher (p < 0.05) in the FED group than in the MED group, and there was less blood loss; Conclusions: The pain-relieving effect of FED in treating LDH was almost identical to that of MED. However, FED was superior to MED in preventing disc height loss, which is one of the indicators of postoperative disc degeneration.