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  • Original Article

    Comparison of Outcomes of Percutaneous Endoscopic Lumbar Discectomy

    and Open Lumbar Microdiscectomy for Young Adults: A Retrospective Matched Cohort Study

    Sang-Soak Ahn1, Sang-Hyeon Kim2, Dong-Won Kim2, Byung-Hun Lee3

    -OBJECTIVE: There have been only a few studies on surgical treatment of lumbar disc herniation (LDH) in young adults. In addition, previous studies do not provide detailed information on the surgical outcomes for young adults with LDH. The purpose of this study was to compare the outcome of transforaminal percutaneous endoscopic lum- bar discectomy (PELD) and open lumbar microdiscectomy for active, young adults (age 20e25 years).

    -METHODS: We performed retrospective chart and radi- ography. The patients were divided into 2 groups according to the surgical methods. Group A included the patients who underwent transforaminal PELD, and Group B included the patients who underwent open lumbar microdiscectomy for LDH at L4/5. After we matched for several factors, 32 young patients in group A and 34 young patients in group B were analyzed. We compared the outcomes between the 2 groups in terms of clinical, radiologic, perioperative out- comes, and surgery-related complications.

    -RESULTS: The clinical results for leg pain and radiologic results for decompression were the same in both groups. Most of complications in the PELD group occurred in the early phase. The recurrence rate and operation failure rate was no difference between the groups. The PELD brought significant advantages in the following areas: back pain, operation time, blood loss, hospital stay, and return-to- work.

    Key words - Diskectomy - Percutaneous - Endoscopy - Intervertebral disc displacement - Young adult

    Abbreviations and Acronyms DSCSA: Dural sac cross-sectional area LDH: Lumbar disc herniation MRI: Magnetic resonance imaging ODI: Oswestry Disability Index OLM: Open lumbar microdiscectomy PELD: Percutaneous endoscopic lumbar diskectomy PLL: Posterior longitudinal ligament SF-12: 12-item short form health survey

    250 www.SCIENCEDIRECT.com WORLD NEU

    -CONCLUSIONS: Although a learning curve is needed in order to become familiar with PELD, PELD seemed to be a good choice for disc herniation in the lumbar spine for active, young adults.

    INTRODUCTION

    umbar disc herniation (LDH) is a relatively common cause of sciatica in young adults.1-5 Most young adults with LDH

    Lcan be managed properly with conservative treatment;

    however, a small number of patients do not respond effectively to conservative treatment and eventually require surgical treatment. There are 2 main surgical options: open lumbar microdiscectomy (OLM) and percutaneous endoscopic lumbar discectomy (PELD). OLM has been considered to be the gold standard procedure for symptomatic lumbar disc diseases1,6-9; however, open surgery results in muscle damage, the removal of the yellow ligament, and nerve retraction. This can cause instability and scarring of the epidural space, which becomes clinically symptomatic in 10% or more of patients.6,7,9,10 PELD has been performed as an alternative to classic open discectomy with comparable results. There are potential downsides of the tranforaminal PELD, such as transient paresthesias, a larger annular defect, and difficulties accessing L5/S1 in patients with a prominent iliac crest. In addition, the learning curve is perceived to be steep. However, it has several advantages over open discectomy, including (1) the ability to be performed under local anesthesia; (2) minimal postoperative pain

    VAS: Visual analog scale

    From the 1Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, Seoul; 2Department of Radiology, Dong-A University Medical Center, Busan; and 3Department of Neurosurgery, The Armed Forces Capital Hospital, Seongnam, Korea

    To whom correspondence should be addressed: Sang-Soak Ahn, M.D. [E-mail: ahnsangsoak@hanmail.net]

    Citation: World Neurosurg. (2016) 86:250-258. http://dx.doi.org/10.1016/j.wneu.2015.09.047

    Journal homepage: www.WORLDNEUROSURGERY.org

    Available online: www.sciencedirect.com

    1878-8750/$ - see front matter ª 2016 Elsevier Inc. All rights reserved.

    ROSURGERY, http://dx.doi.org/10.1016/j.wneu.2015.09.047

    http://crossmark.crossref.org/dialog/?doi=10.1016/j.wneu.2015.09.047&domain=pdf mailto:ahnsangsoak@hanmail.net http://dx.doi.org/10.1016/j.wneu.2015.09.047 http://www.WORLDNEUROSURGERY.org www.sciencedirect.com/science/journal/18788750 www.sciencedirect.com/science/journal/18788750 http://dx.doi.org/10.1016/j.wneu.2015.09.047

  • ORIGINAL ARTICLE

    SANG-SOAK AHN ET AL. PELD VERSUS OLM FOR YOUNG ADULTS

    and preservation of the normal para-spinal muscles; and (3) a minimization of the risk of postoperative epidural scar formation and instability.4,11-18 A consensus on the preferred surgical method in young patients has not been established, however, and there have only been a few studies in which the authors examined the surgical treatment of LDH in young adults.1,2,4,5

    We conducted this study to compare the clinical, radiologic, and perioperative outcomes of transforaminal PELD and OLM for young adults (age 20e25 years) with LDH, as well as the surgery- related complications. To the best of our knowledge, this is the first study to compare the outcomes of PELD and OLM in young adults by the use of a retrospective matched cohort design.

    MATERIALS AND METHODS

    Study Design This study was carried out after we obtained approval from the institutional review board (The Armed Forces Capital Hospital [AFMC-15041-IRB-15-057]). Between May 2012 and January 2014, 178 consecutive patients with LDH who underwent surgical treat- ment were considered for this study. The inclusion criteria were as follows: (1) a soft LDH within the spinal canal in L4�5 (including

    Figure 1. Flowchart depicting patient selection. OLM, lumbar m discectomy.

    WORLD NEUROSURGERY 86: 250-258, FEBRUARY 2016

    the sequestering of material located cranially below the lower edge of the cranial pedicle or caudally not over the middle of the caudal pedicle), with lumbar spine radiographs, computed tomography, and magnetic resonance image (MRI) corresponding to the clinical symptoms; (2) age between 20 and 25 years; (3) nonresponse to at least 8 weeks of conservative treatment, including medication, physical therapy, and injections; (4) a surgical procedure performed by the designated spine surgeon (S.S.A.); and (5) follow-up of at least 1 year. Those who met any of the following criteria were excluded: (1) lateral recess stenosis, hard disc herniation, foraminal and extraforaminal disc herniations, and spinal instability; (2) follow-up of less than 1 year; and (3) an inability to accurately complete the pre- and postoperative questionnaires. Ninety-seven patients were excluded because of these criteria. The patients were divided into 2 groups according to the sur-

    gical methods. Group A included the patients who underwent PELD for disc herniation, and Group B included those who un- derwent OLM. After we matched for tobacco smoking and body mass index between the 2 groups, 32 patients in group A and 34 patients in group B were analyzed (Figure 1). All of these patients were Korean military serviceman at the time of their operations. Before surgery, all patients were informed of the details of the

    icrodiscectomy; PELD, percutaneous endoscopic lumbar

    www.WORLDNEUROSURGERY.org 251

    http://www.WORLDNEUROSURGERY.org

  • ORIGINAL ARTICLE

    SANG-SOAK AHN ET AL. PELD VERSUS OLM FOR YOUNG ADULTS

    surgery, including the anesthesia process, potential complications, and benefits of the procedures. One spine surgeon with 4 years of surgical experience was involved in the study. The selection of the surgical method was based on this surgeon’s recommendation as well as patient preference.

    Clinical Assessment Clinical and demographic data were recorded prospectively. The patients completed a questionnaire consisting of a 10-point visual analog scale (VAS) for low back pain and leg pain pre- operatively and at each follow-up visit. The patients also completed the Oswestry Disability Index (ODI) and a 12-item short form health survey (SF-12) for their quality of life preop- eratively and at each follow-up visit. The physical component summary and mental component summary of the SF-12 were recorded separately. Follow-up visits occurred at 6 and 12 months after surgery. Patients were not allowed to review their previous results. The operation time, blood loss, hospital stay, return-to-work time, complication rate, failure rate, and 12- month reherniation rate were evaluated to assess the outcomes of the procedures.

    Radiologic Assessment All patients underwent MRI preoperatively and at 12 months after surgery. The change in the dural sac cross-sectional area (DSCSA) between the preoperative and the postoperative MRI was evaluated to demonstrate the extent of decompression. This space was drawn by an imaginary area at the narrowest lesion on the T2- weighted axial MRI (Figure 2). The MRI scans were performed using a 1.5-T MRI system (Signa Excite scanner, General Electric Company, Milwaukee, Wisconsin, USA) with a slice thickness of 5 mm. To evaluate the radiologic parameters, two radiologists (S.H.K. and D.W.K.) independently measured the preoperative and postoperative parameters using a picture archiving commu- nication system feature (Marosis 5.0 PACS viewer, Marotech, Seoul, Korea).

    Figure 2. Dural sac cross-sectional area between the preopera (MRI). The space was drawn by an imaginary area at the narrow picture archiving communication system.

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