Introduction
Methods
Objective
Search strategy
Technical procedure | Anatomical features/disorder |
---|---|
Endoscopy | Spine |
Arthroscopy | Back |
Video-assisted surgery | Back pain |
Surgical procedures, minimally invasive | Spinal diseases |
Microsurgery | Disc displacement |
Transforaminal | Intervertebral disc displacement |
Discectomy | Spinal cord compression |
Percutaneous | Sciatica |
Foraminotomy, foraminoplasty discoscopy | Radiculopathy |
Selection of studies
Data extraction
Methodological quality assessment
A | Was the method of randomization adequate? | Y | N | ? |
B | Was the treatment allocation concealed? | Y | N | ? |
C | Were the groups similar at baseline regarding the most important prognostic indicators? | Y | N | ? |
D | Was the patient blinded to the intervention? | Y | N | ? |
E | Was the care provider blinded to the intervention | Y | N | ? |
F | Was the outcome assessor blinded to the intervention? | Y | N | ? |
G | Were co-interventions avoided or similar? | Y | N | ? |
H | Was the compliance acceptable in all groups? | Y | N | ? |
I | Was the drop out rate described and acceptable? | Y | N | ? |
J | Was the timing of the outcome assessment in all groups similar? | Y | N | ? |
K | Did the analysis include an intention to treat analysis? | Y | N | ? |
A | Patient selection/inclusion adequately described? | Y | N | ? |
B | Drop out rate described? | Y | N | ? |
C | Independent assessor? | Y | N | ? |
D | Co-interventions described? | Y | N | ? |
E | Was the timing of the outcome assessment similar? | Y | N | ? |
Data analysis
Results
Search and selection
Study/author, methodology | Main inclusion criteria, main exclusion criteria | Type/level LDH | Interventions/technique/instrumentation | Follow-up: duration and outcome | Comment |
---|---|---|---|---|---|
Hermantin et al. [11], randomized n = 60 | Inclusion criteria | Type: intracanal LDH | Index: arthroscopic microdiscectomy | Follow-up I: mean 31 months (range 19–42), 0% lost to follow-up | |
Radiculopathy | Level: single level, L2–S1 | Pure intradiscal technique Kambin technique biportal: n = 2 | C: mean 32 months (range 21–42), 0% lost to follow-up | ||
Post-tension sign | n = 30 ♀8 ♂22, mean 39 years, range 15–66 | Pain (VAS) I: pre-op. 6.6, follow-up 1.9, difference 4.7 = 71% | |||
Neurological deficit | Control: open Laminotomie, n = 30 ♀13 ♂17, mean 40 years, range 18–67 | C: pre-op. 6.8, follow-up 1.2, difference 5.6 = 82% | |||
Exclusion criteria | Return to work (mean): I: 27, C: 49 days | ||||
Sequestration | GPE (unclear instrument) I: 97%, C: 93% excellent + good | ||||
Previous surgery (same level) | PS (very satisfied) I: 73%, C: 67% | ||||
Central or lateral stenosis | Complications I: 6.7%, C: 0% | ||||
Re-operations I: 6.7%, C: 3.3% | |||||
Hoogland et al. [16], not adequately randomized (birth date) n = 280 | Inclusion criteria | Type: all LDH | Index: transforaminal endoscopic discectomy | Follow-up I: 24 months, 16% lost to follow-up | |
Radiculopathy | Level: single level, L2–S1 | Intradiscal and intracanal technique, Thessys instrumentation, n = 142 ♀50 ♂92, mean 41 years, range 18–60 | C: 24 months, 16% lost to follow-up | ||
Post-tension sign | Control: transforaminal endoscopic discectomy combined with injection of low-dose (1,000 U) chymopapain. n = 138 ♀44 ♂94, mean 40.3 years, range 18–60 | Pain leg (VAS) I: pre-op. 8.0, follow-up 2.0, difference 6.0 = 75% | |||
Neurological deficit | C: pre-op. 8.2, follow-up 1.9, difference 6.3 = 77% | ||||
Exclusion criteria | Pain back (VAS) I: pre-op. 8.2, follow-up 2.6, difference 5.6 = 68% | ||||
Obesity | C: pre-op. 8.2, follow-up 2.8, difference 5.4 = 66% | ||||
Previous surgery (same level) | GPE (MacNab) I: 16% excellent, 33.8% good, 0.9% poor | ||||
C: 63% excellent, 27% good, 0.9% poor NS | |||||
PS I: 85%, C: 93% S | |||||
Recurrence I: 7.4%, C: 4.0% | |||||
Complications I: 2.1%, C: 2.2% NS | |||||
Re-operations I: 6.1%, C: 1.6% | |||||
Krappel et al. [31], not adequately randomized (alternating) n = 40 | Inclusion criteria | Type: not specified | Index: endoscopic transforaminal nucleotomy | Follow-up I: range 24–36 months, 5% lost to follow-up | |
Radiculopathy | Level: single level, L4–S1 | Pure intradiscal technique, Mathews technique, Sofamor–-Danek endoscope, n = 20 ♀? ♂?, mean 41 years, range 36–54 | C: range 24–36 months, 0% lost to follow-up | ||
Post-tension sign | Control: Open nucleotomy, n = 20 ♀? ♂?, mean 39 years, range 25–43 | GPE (MacNab) I: 16% excellent, 68% good, 0% poor | |||
Neurological deficit | C: 15% excellent, 60% good, 0% poor NS | ||||
Exclusion criteria | Return to work I: 100%, C 100% | ||||
Sequestration | Recurrence I: 5%, C 0% | ||||
High iliac crest | Complications I: 0%, C 0% | ||||
Re-operations I: 5%, C 0% | |||||
Lee et al. [34], not adequately randomized, (preference of surgeon) n = 300 | Inclusion criteria | Type: not specified | Index: percutaneous endoscopic laser discectomy (PELD), n = 100 ♀35 ♂65 | Follow-up 12 months, 0% lost to follow-up | Authors included n = 3 patients in satisfactory group after re-operation. These were labelled as ‘adverse effects’ and ‘re-operations’ in this review |
Radiculopathy | Level: single level, L3–S1 | Pure intradiscal technique, Kambin technique | GPE (modified MacNab) I: 29%, C1: 20%, C2: 18% excellent | ||
Exclusion criteria | Control 1: chemonucleolysis, n = 100 ♀24 ♂76 | I: 39%,C1: 35%, C2: 30% good | |||
Sequestration | Control 2: automated percutaneous discectomy, n = 100 ♀28 ♂72 | I: 9%, C1: 18%, C2: 20% poor | |||
Return to work (6 weeks) I: 81%, C1: 67%, C2: 66% | |||||
Complications I: 4%, C1: 10%, C2: 3% | |||||
Re-operations I: 9%, C1: 18%, C2: 20% | |||||
Mayer and Brock [39], randomization not specified n = 40 | Inclusion criteria | Type: not specified | Index: percutaneous endoscopic discectomy | Follow-up 24 months, 0% lost to follow-up | |
Radiculopathy | Level: single level, L2–L5 | Pure intradiscal technique, modified Hjikata instrumentation, n = 20 ♀8 ♂12, mean 40 years, range 12–55 | GPE (S/S-score) I: 70% satisfactory, 0% poor | ||
Post-tension sign | Control: open microdiscectomy, n = 20 ♀6 ♂14, mean 42 years, range 19–63 | C: 65% satisfactory, 15% poor | |||
Neurological deficit | Patient satisfaction I: 55%, C: 55% | ||||
Exclusion criteria | Recurrence I: 5%, C: 0% | ||||
Sequestration | Complications I: 0%, C: 5% | ||||
Previous surgery (same level) | Re-operations I: 15%, C: 5% | ||||
Cauda syndrome | |||||
Segmental instability | |||||
Ruetten et al. [47], not adequately randomized (alternating by independent person) n = 200 | Inclusion criteria | Type: all LDH | Index: endoscopic transforaminal and interlaminar lumbar discectomy | Follow-up I: 24 months, 8% lost to follow-up | Authors excluded n = 6 from analyses due to revision surgery. These were taken into account in this review, n = 41 were operated via a transforaminal endoscopic technique, n = 59 patients were operative via an interlaminar endoscopic technique |
Radiculopathy | Level: single level, L1–S1 | Intracanal technique, YESS, Richard Wolf instrumentation, n = 100 | C: 24 months, 8% lost to follow-up | ||
Neurological deficit | Control: open microdiscectomy, n = 100, mean 43 years, range 20–68 | Pain leg (VAS) I: pre-op.75, follow-up 8, difference 67 = 89% | |||
Exclusion criteria | Overall, n = 200 ♀116 ♂84, mean 43 years, range 20−68 | C: pre-op. 71, follow-up 9, difference 62 = 87% | |||
Not specified | Pain back (VAS) I: pre-op. 19, follow-up 11, difference 8 = 42% | ||||
C: pre-op. 15, follow-up 18, difference −3 = −8.3% | |||||
Functional status: (ODI) I: pre-op. 75, follow-up 20, difference 55 = 73% | |||||
C: pre-op. 73, follow-up 24, difference 49 = 67% | |||||
Patient satisfaction I: 97%, C: 88% | |||||
Return to work (mean) I: 25 days | |||||
C: 49 days S | |||||
Recurrence I: 6.6% C: 5.7% NS | |||||
Complications I: 3%, C: 12% S | |||||
Re-operations I: 6.8% C: 11.5 |
Study, methodology | Main inclusion criteria, main exclusion criteria | Type/level LDH | Interventions/technique/instrumentation | Follow-up: duration and outcome | Comment |
---|---|---|---|---|---|
Kim et al. [26], all patients that underwent the procedures in a certain period | Inclusion criteria | Type: central, paramedian and foraminal LDH | Index: percutaneous transforaminal endoscopic discectomy (PTED) | Follow-up: mean 23.6 months (range 18–36), I: 2.5%, C: 3.5% non-responders | |
Radiculopathy | Level: single level, L1–S1 | Intradiscal and intracanal technique, YESS, Richard Wolf instrumentation, n = 295 ♀107 ♂188, mean 35 years, range 13–83 | GPE (MacNab) I: 47% excellent, 37% good, 5.4% poor | ||
C: 48% excellent, 37% good, 6.6% poor NS | |||||
Post-tension sign | Control: open microdiscectomy, n = 607 ♀215 ♂392, mean 44 years, range 17–80 | Recurrence I: 6.4% C: 6.8% NS | |||
Neurological deficit | Complications I: 3.1% C: 2.0% NS | ||||
Exclusion criteria | Re-operations I: 9.5% C: 6.3% NS | ||||
Extraforaminal LDH | |||||
Previous surgery (same level) | |||||
Spinal stenosis | |||||
Segmental instability | |||||
Spondylolisthesis | |||||
Lee et al. [32], randomly selected patients with follow-up > 3 years in both groups | Inclusion criteria | Type: not specified | Index: percutaneous endoscopic lumbar discectomy (PELD) | Follow-up I: mean 38 months (range 32–45), 0% lost to follow-up | Primary outcome of the study was a radiologic evaluation |
Radiculopathy | Level: single level, L4–S1 | Pure intradiscal technique, instrumentation not specified, n = 30 ♀8 ♂22, mean 40 years, range 22–67 | C: 35–42 (36) months, 0% non-responders | ||
Exclusion criteria | Control: open microdiscectomy, n = 30 ♀8 ♂22, mean 40 years, range 20–64 | GPE (MacNab) I: 80% excellent, 17% good, 3.3% poor | |||
Stenosis | C: 78% excellent, 17% good, 0% poor | ||||
Segmental instability | Complications I: 0%, C: 0% | ||||
Re-operations I: 3.3%, C: 0% |
Study | Main inclusion criteria, main exclusion criteria | Number of participants type/level LDH | Interventions/technique/instrumentation | Follow-up: duration and outcome | Comment |
---|---|---|---|---|---|
Hoogland et al. [17] | Inclusion criteria | n = 262 ♀76 ♂186, mean 46 years, range 18–80 | Endoscopic transforaminal discectomy (ETD) | Follow-up: 24 months, 9% lost to follow-up | Authors included only patients with recurrent LDH, more than 6 months after open microdiscectomy or endoscopic surgery |
Previous surgery (same level) | Type: all LDH | Intradiscal and intracanal technique | Pain leg (VAS): pre-op. 8.5, follow-up 2.6, differences 5.9 = 69% | ||
Recurrent disc herniation | Level: single level, L2–S1 | Thessys instrumentation | Pain back (VAS): pre-op. 8.6, follow-up 2.9, difference 5.7 = 66% | ||
Radiculopathy | GPE (MacNab): 31% excellent, 50% good, 2.5% poor | ||||
Post-tension sign | Patient satisfaction: 51% excellent, 35% good, 5% poor | ||||
Neurological deficit | Recurrence: 6.3% | ||||
Exclusion criteria | Complications: 1.1% | ||||
Not specified | Re-operations: 7% | ||||
Hoogland and Schenkenbach [15] Schenkenbach and Hoogland [51] | Inclusion criteria | n = 130 ♀43 ♂87, mean 39 years | Endoscopic transforaminal discectomy (ETD) | Follow-up: 12 months, 5.1% lost to follow-up | |
Radiculopathy | Type: all LDH | Intradiscal and intracanal technique | Pain leg (VAS): difference 5.9 | ||
Post-tension sign | Level: single level, L2–S1 | Thessys instrumentation | Pain back (VAS): difference 5.4 | ||
Neurological deficit | GPE (MacNab): 56% excellent, 27% good, 6% poor | ||||
Exclusion criteria | Return to work (6 weeks): 70% | ||||
Not specified | Complications: 1.5% | ||||
Re-operations: 4.6% | |||||
Kafadar et al. [20] | Inclusion criteria | n = 42 ♀2 ♂40, range 18–74 years | Percutaneous endoscopic transforaminal discectomy (PETD) | Follow-up: mean 15 months (range 6–24) (SD 4), 0% lost to follow-up | Authors excluded n = 8 from analyses due to stopped procedures. These were taken into account in this review |
Radiculopathy | Type: all LDH | Pure intradiscal technique | GPE (S/S-score): 14% excellent, 36% good 36% poor | ||
Post-tension sign | Level: single level, L4–L5 | Karl Storz instrumentation | Recurrence: 0% | ||
Neurological deficit | Complications: 45% | ||||
Exclusion criteria | Re-operations: 17% | ||||
Previous surgery(same level) | |||||
Spinal stenosis | |||||
Segmental instability | |||||
Calcified LDH | |||||
Kambin [23]; Kambin | Inclusion criteria | n = 175 ♀76 ♂99 | Arthroscopic microdiscectomy and selective fragmentectomy | Follow-up: mean 48 months (range 24–78), 3.4% lost to follow-up | |
Radiculopathy | Type: all LDH | Pure intradiscal technique | GPE (Modified Presby, St Luke score): 77% excellent, 11% good, 12% failed | ||
Post-tension sign | Level: single level, L2−S1 | Kambin technique | Return to work (3 weeks): 95% | ||
Neurological deficit | Biportal n = 59 | Complications: 5.3% | |||
Exclusion criteria | Re-operations: 7.7% | ||||
Large extraligamental LDH | |||||
Previous surgery (same level) | |||||
Cauda syndrome | |||||
Degenerative disc | |||||
Inclusion criteria | n = 250 ♀? ♂?, mean 48 years, range 21–86 | Endoscopic laser foraminoplasty (ELF) | Follow-up: mean 30 months (range 24–48) (SD 5.87), 3.2% lost to follow-up | Authors included also degenerative and lateral stenosis in this study | |
Prior disc surgery n = 75 | Type: All LDH | Intradiscal and intracanal technique | Pain (VAS > 50% improvement): 56% | ||
Back pain | Level: single and multiple level, L2–S1 | Richard Wolf instrumentation | Functional status (ODI): 60% improved ≥ 50% | ||
Leg pain | Complications: 0.8% | ||||
Radiculopathy | Re-operations: 5.2% | ||||
Exclusion criteria | |||||
Cauda syndrome | |||||
Painless motor deficit | |||||
Lee et al. [33] | Inclusion criteria | n = 116 ♀43 ♂73, mean 36 years, range 18–65 | Percutaneous endoscopic lumbar discectomy (PELD) | Follow-up: mean 14.5 months (range 9–20), 0% lost to follow-up | |
Radiculopathy | Type: not specified | Intradiscal and intracanal technique | Pain leg (VAS): pre-op. 7.5, follow-up 2.6, difference 4.9 = 65% | ||
Neurological deficit | Level: single level, L2–S1 | YESS, Richard Wolf instrumentation | GPE (Modified MacNab): 45% excellent, 47% good, 6.0% poor | ||
Non-contained or sequestered LDH | Return to work: average 14 days, range 1–48 days | ||||
Exclusion criteria | Recurrence: 0% | ||||
Previous surgery (same level) | Complications: 0% | ||||
Central or lateral stenosis | Re-operations: 0% | ||||
Segmental instability | |||||
Morgenstern et al. [42] | Inclusion criteria | n = 144 ♀48 ♂96, mean 46 years, range 18–76 | Endoscopic spine surgery | Follow-up: mean 24 months (range 3–48), 0% lost to follow-up | Primary outcome of this study was to compare normal versus intensive physical therapy post operative revalidation |
Radiculopathy | Type: all LDH | Intradiscal and intracanal technique | GPE (MacNab): 83% excellent and good, 3% poor | ||
Neurological deficit | Level: multiple level n = 60, L1–S1 | YESS, Richard Wolf instrumentation | Complications: 9% | ||
Exclusion criteria | Re-operations: 5.6% | ||||
Sequestration | |||||
Ramsbacher et al. [45] | Inclusion criteria | n = 39 ♀21 ♂18, mean 50 years | Transforaminal endoscopic sequestrectomy (TES) | Follow-up: 6 weeks, 0% lost to follow-up | |
Radiculopathy | Type: all LDH | Intracanal technique | Pain leg (VAS): pre-op. 6.7, follow-up 0.8, difference 5.9 = 88% | ||
Neurological deficit | Level: single level, L3–S1 | Sofamor–Danek endoscope | Pain back (VAS): pre-op. 5.1, follow-up 1.3, difference 3.8 = 74% | ||
Exclusion criteria | PS: 77% (very satisfied + satisfied) | ||||
Far migrated sequesters | Complications: 5.1% | ||||
Central or lateral stenosis | Re-operations: 10% | ||||
High iliac crest | |||||
Ruetten et al. [46] | Inclusion criteria | n = 517 ♀277 ♂240, mean 38 years, range 16–78 | Extreme-lateral transforaminal approach | Follow-up: 12 months, 10% lost to follow-up | |
Radiculopathy | Type: all LDH | Intracanal technique, Richard Wolf instrumentation, n = 27 bilateral | Pain leg (VAS): pre-op. 7.1, follow-up 0.8, difference 6.3 = 89% | ||
Neurological deficit | Level: multiple level n = 46, L1–L5 | Pain back (VAS): pre-op. 1.8, follow-up 1.6, difference 0.2 = 13% | |||
Exclusion criteria | Functional status (ODI): pre-op. 78, follow-up 20, difference 58 = 74% | ||||
Far cranial/caudal migrated sequester | Recurrence: 6.9% | ||||
Previous surgery (same level) | Complications: 0% | ||||
Spinal stenosis | Re-operations: 6.9% | ||||
Sasani et al. [48] | Inclusion criteria | n = 66 ♀36 ♂30, median 52 years, range 35–73 | Percutaneous endoscopic discectomy (PED) | Follow-up: 12 months, 0% lost to follow-up | |
Radiculopathy | Type: foraminal + extraforaminal LDH | Pure intradiscal technique Karl Storz instrumentation | Pain (VAS): pre-op. 8.2, follow-up 1.2, difference 7.0 = 85% | ||
Post-tension sign | Level: single level, L2–L5 | Functional status (ODI): pre-op. 78, follow-up 8, difference 70 = 90% | |||
Neurological deficit | Complications: 6.1% | ||||
Exclusion criteria | Re-operations: 7.6% | ||||
Previous surgery (same level) | |||||
Schubert and Hoogland [54] | Inclusion criteria | n = 558 ♀179 ♂379, mean 44 years, range 18–65 | Transforaminal nucleotomy with foraminoplasty | Follow-up: 12 months, 8.7% lost to follow-up | |
Radiculopathy | Type: all LDH | Intracanal technique, Thessys instrumentation | Pain leg (VAS): pre-op. 8.4, follow-up 1.0, difference 7.4 = 88% | ||
Post-tension sign | Level: single level, L2–S1 | Pain back (VAS): pre-op. 8.6, follow-up 1.4, difference 7.2 = 84% | |||
Neurological deficit | GPE (MacNab): 51% excellent, 43% good, 0.3% poor | ||||
Sequestration | Recurrence: 3.6% | ||||
Exclusion criteria | Complications: 0.7% | ||||
Previous surgery (same level) | Re-operations: 3.6% | ||||
Suess et al. [57] | Inclusion criteria | n = 25 ♀11 ♂14, mean 48 years, range 26–72 | Percutaneous transforaminal endoscopic sequestrectomy (PTFES) | Follow-up: 6 weeks, 0% lost to follow-up | All patients operated under general anaesthesia and EMG monitoring |
Radiculopathy | Type: foraminal + extraforaminal LDH | Pure intradiscal technique, instrumentation not specified | Pain leg (VAS): pre-op. 6.7, follow-up 0.8, difference 5.9 = 88% | ||
Neurological deficit | Level: single level, L2–L5 | Pain back (VAS): pre-op. 5.1, follow-up 1.3, difference 3.8 = 75% | |||
Exclusion criteria | Complications: 4% | ||||
Cauda syndrome | Re-operations: 8% | ||||
Spinal stenosis |
Study | Main inclusion criteria, main exclusion criteria | Type /level LDH | Interventions/technique/instrumentation | Follow-up: duration and outcome | Comment |
---|---|---|---|---|---|
Ahn et al. [3] | Inclusion criteria | n = 43 ♀11 ♂32, mean 46 years, range 22–72 | Percutaneous endoscopic lumbar discectomy (PELD) | Follow-up: range 24–39 months, 0% non-responders | Authors included only patients with recurrent LDH, more than 6 months after open microdiscectomy |
Prior disc surgery | Type: all LDH | Intradiscal and intracanal technique, instrumentation not specified | Pain (VAS): pre-op. 8.7, follow-up 2.6, difference 6.1 = 70% | ||
Radiculopathy | Level: single level, L3–S1 | GPE (MacNab): 28% excellent, 53% good, 4.7% poor | |||
Post-tension sign | Complications: 4.6% | ||||
Neurological deficit | Re-operations: 2.3% | ||||
Exclusion criteria | |||||
Segmental instability | |||||
Spondylolisthesis | |||||
Calcified fragments | |||||
Chiu [5] | Inclusion criteria | n = 2,000 ♀990 ♂1010, mean 44 years, range 24–92 | Transforaminal microdecompressive endoscopic assisted discectomy (TF-MEAD) | Follow-up: mean 42 months (range 6–72), 0% non-responders | Authors included also patients with stenosis and degenerative disc disease |
Virgin and prior disc surgery | Type: not specified | Intradiscal and intracanal technique | GPE (unclear instrument): 94% excellent or good, 3% poor | ||
Pain in back | Level: single and multiple level | Karl Storz instrumentation | Complications: 1% | ||
Radiculopathy | Re-operations: not specified | ||||
Neurological deficit | |||||
Exclusion criteria | |||||
Cauda syndrome | |||||
Painless motor deficit | |||||
Choi et al. [6] | Inclusion criteria | n = 41, ♀23 ♂18, mean 59 years, range 32–74 | Extraforaminal targeted fragmentectomy | Follow-up: mean 34 months (range 20–58), 4.9% non-responders | |
Radiculopathy | Type: extraforaminal LDH | Pure intradiscal technique, YESS, Richard Wolf instrumentation | Pain leg (VAS): pre-op. 8.6, follow-up 1.9, difference 6.7 = 78% | ||
Post-tension sign | Level: single level, L4–S1 | Return to work: mean 6 weeks (range 4–24) | |||
Neurological deficit | Functional status (ODI): pre-op. 66.3, follow-up 11.5, difference 54.8 = 83% | ||||
Exclusion criteria | PS: 92% | ||||
Previous surgery (same level) | Recurrence: 5.1% | ||||
Central or lateral stenosis | Complications: 5.1% | ||||
Segmental instability | Re-operations: 7.7% | ||||
Calcified disc | |||||
Ditsworth [7] | Inclusion criteria | n = 110 ♀40 ♂70, median 55 years, range 20 to > 60 | Endoscopic transforaminal lumbar discectomy | Follow-up: range 24–48 months, 0% non-responders | |
Radiculopathy | Type: all LDH | Intradiscal and intracanal technique | GPE (MacNab): 91% excellent or good, 4.5% poor | ||
Post-tension sign | Level: single level | Flexible endoscope | Recurrence: 0% | ||
Neurological deficit | Complications: 0.9% | ||||
Exclusion criteria | Re-operations: 4.5% | ||||
Spinal stenosis | |||||
Segmental instability | |||||
Eustacchio [8] | Inclusion criteria | n = 122 ♀36 ♂86, median 55 years, range 18–89 | Endoscopic percutaneous transforaminal treatment | Follow-up: mean 35 months (range 15–53), 0% non-responders | Authors excluded n = 10 from analyses due to stopped procedures. These were taken into account in this review |
Radiculopathy | Type: all LDH | Intradiscal and intracanal technique instrumentation not specified | GPE (MacNab): 45% excellent, 27% good, 27% poor | ||
Post-tension sign | Level: multiple level n = 4, L2–S1 | Functional status (PROLO): 71.9% excellent or good | |||
Neurological deficit | Return to work: 94% | ||||
Exclusion criteria | Recurrence: 12% | ||||
Cauda syndrome | Complications: 9% | ||||
Re-operations: 27% | |||||
Haag [10] | Inclusion criteria | n = 101 | Transforaminal endoscopic microdiscectomy | Follow-up: mean 28 months (range 15–26), 9% non-responders | Authors excluded n = 3 from analyses due to technical problems during procedures. These were taken into account in this review |
Radiculopathy | Type: all LDH | Pure intradiscal technique | PS: good: 66%, satisfied: 9%, poor: 25% | ||
Neurological deficit | Level: single level, L2–S1 | Sofamor–Danek instrumentation | Complications: 7.6% | ||
Exclusion criteria | Re-operations: 17% | ||||
Discus narrowing | |||||
Calcified disc | |||||
Hochschuler [13] | Inclusion criteria | n = 18 ♀5 ♂13, mean 31 years, range 18–55 | Arthroscopic microdiscectomy (AMD) | Follow-up: mean 9 months (range 4–13), 0% non-responders | |
Radiculopathy | Type: not specified | Pure intradiscal technique | Re-operations: 11% | ||
Exclusion criteria | Level: L3−S1 | Kambin technique | |||
Previous operation (same level) | |||||
Sequestration | |||||
High iliac crest | |||||
Hoogland [14] | Inclusion criteria | n = 246 | Transforaminal endoscopic discectomy with foraminoplasty | Follow-up: 24 months, 0% non-responders | Authors included also patients with foraminal stenosis |
Not specified | Type: not specified | Intracanal technique, Thessys instrumentation | GPE (MacNab): 86% excellent or good, 7.7% poor | ||
Exclusion criteria | Level: not specified | Complications: 1.2% | |||
Not specified | Re-operations (1st year): 3.5% | ||||
Iprenburg [18] | Inclusion criteria | n = 149 ♀62 ♂87, mean 43 years, range 17–82 | Transforaminal endoscopic surgery | Follow-up: not specified, 29% non-responders | |
Not specified | Type: all LDH | Intracanal technique, Thessys instrumentation | Pain (VAS): not specified | ||
Exclusion criteria | Level: single level, L3–S1 | Functional status (ODI): not specified | |||
Central stenosis | Recurrence: 6% | ||||
Complications: not specified | |||||
Re-operations: not specified | |||||
Jang et al. [19] | Inclusion criteria | n = 35 ♀20 ♂15, mean 61 years, range 22–84 | Transforaminal percutaneous endoscopic discectomy (TPED) | Follow-up: mean 18 months (range 10–35), 0% non-responders | |
Radiculopathy | Type: foraminal and extraforaminal LDH | Intradiscal and intracanal technique, instrumentation not specified | Pain (VAS): pre-op. 8.6, follow-up 3.2, difference 5.4 = 63% | ||
Exclusion criteria | Level: single level, L2–S1 | GPE (MacNab): 86% excellent or good, 8.6% poor | |||
Previous surgery (same level) segmental instability | Recurrence: 0% | ||||
Spinal stenosis | Complications: 17% | ||||
Listhesis | Re-operations: 8.6% | ||||
Lew et al. [35] | Inclusion criteria | n = 47 ♀12 ♂35, mean 51 years, range 30–70 | Transforaminal percutaneous endoscopic discectomy | Follow-up: mean 18 months (range 4–51), 0% non-responders | |
Radiculopathy | Type: foraminal and extraforaminal LDH | Pure intradiscal technique | GPE (MacNab): 85% excellent or good, 11% poor | ||
Post-tension sign | Level: L1–L5 | Surgical dynamics instrumentation | Return to work: 89% | ||
Neurological deficit | Complications: 0% | ||||
Exclusion criteria | Re-operations: 11% | ||||
Previous surgery (same level) | |||||
Mayer and Brock [39] | Inclusion criteria | n = 30 ♀11 ♂19 | Percutaneous endoscopic lumbar discectomy (PELD) | Follow-up: range 6–18 months, 0% non-responders | Twenty of the patients were described in a prospective study [41]. In this review reoperations were labelled as moderate or poor outcome on GPE |
Radiculopathy | Type: not specified | Pure intradiscal technique, instrumentation not specified | GPE (S/S-score): 67% excellent or good, 33% moderate or poor | ||
Post-tension sign | Level: multiple level n = 1, L2–L5 | Return to work: 7.1 ± 4.2 weeks, 90% (6 months) | |||
Neurological deficit | Complications: 3.3% | ||||
Exclusion criteria | Re-operations: 3.3% | ||||
Sequestration | |||||
Previous surgery (same level) | |||||
Cauda syndrome | |||||
Segmental instability | |||||
Spinal stenosis | |||||
Listhesis | |||||
Inclusion criteria | n = 300 ♀132 ♂168, range 16–81 years | Percutaneous lumbar discectomy with endoscope | Follow-up: 6 months, 0% non-responders | ||
Radiculopathy | |||||
Post tension sign | Type: not specified | Pure intradiscal technique, Kambin technique | Return to work (6 months): 67% | ||
Neurological deficit | |||||
Exclusion criteria | Level: multiple level n = 40, L2–S1 | Complications: 5.3% | |||
Previous surgery (same level) | |||||
Sequestration | Re-operations: 1.3% | ||||
Obesity | |||||
Inclusion criteria | n = 174 ♀68 ♂106, mean 39 years, range 16–81 | Percutaneous nucleotomy with discoscopy | Follow-up: mean 28 months, 0% non-responders | Authors included also patients with degenerative disc disease, only the scores from LDH are quoted in this review | |
Radiculopathy | Type: not specified | Pure intradiscal technique | GPE (S/S-score): 85% excellent or good | ||
Exclusion criteria | Level: multiple level n = 25 | Modified Hijikata instrumentation biportal | Complications: 10% | ||
Sequestration | Re-operations: 21% | ||||
Shim et al. [56] | Inclusion criteria | n = 71 ♀39 ♂32, mean 45 years, range 21–74 | Transforaminal endoscopic surgery | Follow-up: mean 6 months (range 3–9), 0% non-responders | n = 14 patients with L5−S1 level LDH are operated via a interlaminar approach |
Radiculopathy | Type: not specified | Pure intradiscal technique | GPE (MacNab): 33% excellent, 45% good, 6.5% poor | ||
Exclusion criteria | Level: single level, T12–S1 | YESS, Richard Wolf instrumentation | Complications: 2.8% | ||
Not specified | Re-operations: 7.0% | ||||
Tsou and Yeung [59] | Inclusion criteria | n = 219 ♀83 ♂136, mean 42 years range 17–71 | Transforaminal endoscopic decompression | Follow-up: mean 20 months (range 12–108), 11.9% non-responders | Possible patient overlap with other study [65] |
Radiculopathy | Type: central LDH | Intradiscal and intracanal technique | GPE (MacNab): 91% excellent or good, 5.2% poor | ||
Neurological deficit | Level: single level, L3–S1 | YESS, Richard Wolf instrumentation | Recurrence: 2.7% | ||
Exclusion criteria | Complications: 2.7% | ||||
Sequestration | Re-operations: 4.6% | ||||
Previous operation (same level) | |||||
Tzaan [60] | Inclusion criteria | n = 134 ♀56 ♂78, mean 38 years, range 22–71 | Transforaminal percutaneous endoscopic lumbar discectomy (TPELD) | Follow-up: mean 38 months (range 3–36), 0% non-responders | |
Pain in leg and back | Type: all LDH | Pure intradiscal technique | GPE (modified MacNab): 28% excellent, 61% good, 3.7% poor | ||
Exclusion criteria | Level: multiple level n = 20, L2–S1 | Instrumentation not specified | Recurrence: 0.7% | ||
Sequestration | Complications: 6.0% | ||||
Spinal stenosis | Re-operations: 4.5% | ||||
Calcified disc | |||||
Segmental instability | |||||
Cauda syndrome | |||||
Wojcik [62] | Inclusion criteria | n = 43 ♀25 ♂18, mean 30 years | Endoscopically assisted percutaneous lumbar discectomy | Follow-up: 18 months, 16.3% non-responders | |
Radiculopathy | Type: not specified | Pure intradiscal technique | GPE (unclear instrument): 64% good, 36% satisfied, 0% poor | ||
Exclusion criteria | Level: not specified | Modified Hijikata instrumentation | Complications: not specified | ||
Sequestration | Re-operations: not specified | ||||
Chronic back pain | |||||
Yeung and Tsou [65] | Inclusion criteria | n = 307 ♀102 ♂205, mean 42 years, range 18–72 | Posterolateral endoscopic excision for lumbar disc herniation | Follow-up: mean 19 months (range 12–?), 8.8% non-responders | Possible patient overlap with other study [65] |
Prior disc surgery n = 31 | Type: all LDH | Intradiscal and intracanal technique | GPE (MacNab): 84% excellent or good, 9.3% poor | ||
Radiculopathy | Level: single level, L2–S1 | YESS, Richard Wolf instrumentation | Recurrence: 0.7% | ||
Neurological deficit | Complications: 3.9% | ||||
Exclusion criteria | Re-operations: 4.6% | ||||
Sequestration | |||||
Central and lateral stenosis |
Type of studies and methodological quality
Outcomes
Outcome measure (instrument) | Studies (patients) | Outcome median (min–max) |
---|---|---|
Pain leg (VAS) | 7 (n = 1,558) | 88% (65–89%) improvement |
Pain back (VAS) | 5 (n = 1,401) | 74% (13–84%) improvement |
Pain (region not specified) (VAS) | 3 (n = 144) | 70% (63–85%) improvement |
GPE (MacNab) | 15 (n = 2,544) | 85% (72–94%) satisfactory |
6% (0.3–27%) poor | ||
Functional status (ODI) | 3 (n = 624) | 83% (74–90%) improvement |
Patient satisfaction | 3 (n = 181) | 78% (75–92%) satisfactory |
Return to work | 5 (n = 757) | 90% (67–95%) |
Recurrence | 13 (n = 2,612) | 1.7% (0–12%) |
Complication | 28 (n = 6,336) | 2.8% (0–40%) |
Re-operation | 28 (n = 4,135) | 7% (0–27%) |
Outcome measure (instrument) | Studies | Outcome median (min–max) |
---|---|---|
Pure intradiscal technique 14 studies (n = 1,267) intradiscal technique | ||
Pain leg (VAS) | 2 (n = 66) | 83% (78–88%) improvement |
Pain back (VAS) | 1 (n = 25) | 75% improvement |
Pain (region not specified) (VAS) | 1 (n = 66) | 85% improvement |
GPE (MacNab) | 3 (n = 279) | 85% (78–89%) satisfactory |
6.5% (3.7–11%) poor | ||
Recurrence | 3 (n = 217) | 0.7% (0–5.1%) |
Complication | 12 (n = 1,206) | 5.3 % (0–40%) |
Re-operation | 14 (n = 1,267) | 7.5% (1.3–30%) |
Intracanal technique 16 studies (n = 4,985) | ||
Pain leg (VAS) | 5 (n = 1,524) | 88% (65–89%) improvement |
Pain back (VAS) | 4 (n = 1,408) | 70% (13–84%) improvement |
Pain (region not specified) (VAS) | 2 (n = 78) | 67% (63–70%) improvement |
GPE (MacNab) | 12 (n = 2,292) | 86% (72–93%) satisfactory |
6% (0.3–9.3%) poor | ||
Recurrence | 10 (n = 2,395) | 3.2% (0–12%) |
Complication | 17 (n = 5,362) | 2.1% (0–17%) |
Re-operation | 15 (n = 3,098) | 4.6% (0–27%) |
Outcome measure (instrument) | Studies | Outcome median (min–max) |
---|---|---|
Type: far-lateral LDH 6 studies (n = 214) | ||
Pain (region not specified) (VAS) | 4 (n = 167) | 82% (63–88%) improvement |
GPE (MacNab) | 2 (n = 52) | 86% (85–86%) satisfactory |
9.8% (8.6–11%) poor | ||
Functional status (ODI) | ||
Recurrence | 2 (n = 76) | 2.6% (0–5.1%) |
Complication | 5 (n = 214) | 5.1% (0–17%) |
Re–operation | 5 (n = 214) | 8.0% (7.6–11%) |
Type: central LDH 1 study (n = 71) | ||
GPE (MacNab) | 1 (n = 71) | 91% satisfactory |
12% poor | ||
Complication | 1 (n = 71) | 2.7% |
Re-operation | 1 (n = 71) | 4.6% |
Type: all LDH 15 studies (n = 3,067) | ||
Pain leg (VAS) | 4 (n = 1,374) | 88% (69–89%) improvement |
Pain back (VAS) | 4 (n = 1,374) | 70% (13–84%) improvement |
Pain (region not specified) (VAS) | 1 (n = 43) | 70% improvement |
GPE (MacNab) | 9 (n = 1,810) | 83% (79–94%) satisfactory |
4.6% (0.3–9.3%) poor | ||
Recurrence | 9 (n = 2,201) | 3.6% (0–12%) |
Complication | 15 (n = 2,934) | 4.9% (0–45%) |
Re-operation | 15 (n = 2,934) | 5.6% (2.3–27%) |
Outcome measure (instrument) | Studies | Outcome median (min–max) |
---|---|---|
Endoscopic (index) versus open microdiscectomy (control) | ||
Pain leg (VAS) | 1 (n = 200) | Index 89% improvement |
Control 87% improvement | ||
Pain back (VAS) | 1 (n = 200) | Index 42% improvement |
Control −8.3% improvement | ||
Pain (region not specified) (VAS) | 1 (n = 60) | Index 71% improvement |
Control 82% improvement | ||
GPE (MacNab/other) | 5 (n = 1,102) | Index 84% (70–97%) satisfactory |
1.7% (0–5.4%) poor | ||
Control 78% (65–93%) satisfactory | ||
3.3% (0–15%) poor | ||
Recurrences | 4 (n = 1,182) | Index 5.7% (5–6.6%) |
Control 2.9% (0–6.8%) | ||
Complications | 6 (n = 1,302) | Index 1.5% (0–6.7%) |
Control 1.0% (0–12%) | ||
Re-operations | 6 (n = 1,302) | Index 6.8% (3.3–15%) |
Control 4.7 % (0–11.5%) |