J Neurol Surg A Cent Eur Neurosurg 2021; 82(03): 218-224
DOI: 10.1055/s-0040-1721019
Original Article

Comparison of the Minimally Invasive Tubular Transmuscular Approach with the Conventional Microsurgical Approach for Microsurgical Treatment of Lumbar Disk Herniation: A Prospective Randomized Study

Bogdan Pintea
1   Department of Neurochirurgie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Germany
2   Department of Neurosurgery, Universitätsklinikum Bonn Zentrum für Nervenheilkunde, Bonn, Nordrhein-Westfalen, Germany
Nadine Krämer
2   Department of Neurosurgery, Universitätsklinikum Bonn Zentrum für Nervenheilkunde, Bonn, Nordrhein-Westfalen, Germany
Andreas Müller
2   Department of Neurosurgery, Universitätsklinikum Bonn Zentrum für Nervenheilkunde, Bonn, Nordrhein-Westfalen, Germany
3   Department of Neurosurgery, Medizinische Fäkultat der RWTH Aachen, Aachen, Germany
Matthias Florian Geiger
2   Department of Neurosurgery, Universitätsklinikum Bonn Zentrum für Nervenheilkunde, Bonn, Nordrhein-Westfalen, Germany
3   Department of Neurosurgery, Medizinische Fäkultat der RWTH Aachen, Aachen, Germany
Martin Podlogar
2   Department of Neurosurgery, Universitätsklinikum Bonn Zentrum für Nervenheilkunde, Bonn, Nordrhein-Westfalen, Germany
Patrick Weber
4   Department of Movement and Neurosciences, Deutsche Sporthochschule Köln, Koln, Nordrhein-Westfalen, Germany
Rudolf Andreas Kristof
2   Department of Neurosurgery, Universitätsklinikum Bonn Zentrum für Nervenheilkunde, Bonn, Nordrhein-Westfalen, Germany
5   Department of Neurosurgery, HELIOS Klinikum Meiningen, Meiningen, Thüringen, Germany
› Author Affiliations


Background The aim of this study is to compare the outcome of the minimally invasive transmuscular approach using a tubular retractor system (Metrx) with the conventional microsurgical standard approach (CM) for microsurgical treatment of lumbar disk herniation.

Methods This is a prospective randomized controlled study with a 1:1 distribution of patients in CM and Metrx study groups. Two hundred and twenty-seven (117 CM and 110 Metrx) patients were included. The primary outcome parameters are postoperative pain intensity reduction, length of hospitalization, postoperative quality of life, and daily life performance based on the standardized questionnaires: Visual Analog Scale (VAS), 36-Item Short Form Survey (SF-36), Oswestry Disability Index (ODI), and Prolo scores. The secondary outcome parameters are intraoperative variables: surgery duration, blood loss, and fluoroscopy dose.

Results There were no significant statistical differences in the primary outcome measures between the two groups with respect to postoperative pain relief (median VAS pre-op to 3 months post-op for sciatica: 9–2 [CM] vs. 8–2 [Metrx]; for lumbago: 7–2.5 [CM] vs. 6–3 [Metrx]), the length of hospitalization (median of 5 days), or the frequency of occupational reintegration after 3 months (59.1 vs. 60.7%).

Conclusion The microsurgical therapy of lumbar disk herniation via a Metrx approach is a safe and effective treatment option and is equivalent to the CM approach.

Informed Consent

Gratitude is expressed to all patients, who gave their informed consent to participate in the trial and for publication of the data.

Availability of data and material: Data and material disclosure to third parties is not envisaged, and has to be proven by the ethics committee in detail.

Authors' Contributions

Prof. Rudolf Andreas Kristof, MD, was responsible for the study concept and design; Bogdan Pintea, MD, and Prof. Rudolf Andreas Kristof, MD, were responsible for drafting the manuscript and preparation of the final version of the manuscript. Krämer Nadine, MS (medical student), contributed substantially and gave intellectual input. Bogdan Pintea, MD, Nadine Krämer, Matthias Florian Geiger, MD, Andreas Müller, MD, PhD, and Martin Podlogar, MD, were responsible for data collection. Bogdan Pintea, MD, and Weber Patrick were responsible for data analysis.

Publication History

Received: 13 December 2019

Accepted: 07 April 2020

Article published online:
24 January 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
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  • References

  • 1 Mayer C, Siems W. 100 Krankheitsbilder in der Physiotherapie. Berlin: Springer; 2011
  • 2 Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am 2006; 88 (Suppl. 02) 21-24
  • 3 Blamoutier A. Surgical discectomy for lumbar disc herniation: surgical techniques. Orthop Traumatol Surg Res 2013; 99 (01) S187-S196
  • 4 Brunori A, De Caro GM, Giuffrè R. Surgery of lumbar disk hernia: historical perspective. Ann Ital Chir 1998; 69 (03) 285-293
  • 5 Caspar W. A new surgical procedure for lumbar disc herniation causing less tissue damage through a microsurgical approach. Adv Neurosurg 1977; 4: 74-77
  • 6 Prolo DJ, Oklund SA, Butcher M. Toward uniformity in evaluating results of lumbar spine operations. A paradigm applied to posterior lumbar interbody fusions. Spine 1986; 11 (06) 601-606
  • 7 Ruetten S, Komp M, Merk H, Godolias G. Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study. Spine 2008; 33 (09) 931-939
  • 8 Foley KT, Smith MM. Microendoscopic discectomy. Tech Neurosurg 1997; 3: 301-307
  • 9 Carlsson AM. Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain 1983; 16 (01) 87-101
  • 10 Osthus H, Cziske R, Jacobi E. Cross-cultural adaptation of a German version of the Oswestry Disability Index and evaluation of its measurement properties. Spine 2006; 31 (14) E448-E453
  • 11 Bullinger M, Morfeld M. Der SF-36 Health Survey. In: Schöffski O, Schulenburg v.d.JMG. eds. Gesundheitsökonomische Evaluationen. Berlin: Springer; 2008
  • 12 Ware Jr JE. SF-36 health survey update. Spine 2000; 25 (24) 3130-3139
  • 13 Pogatzki-Zahn EM, Meissner W. Postoperative pain therapy in Germany. Status quo. Schmerz 2015; 29 (05) 503-509
  • 14 Postacchini F, Postacchini R. Operative management of lumbar disc herniation : the evolution of knowledge and surgical techniques in the last century. Acta Neurochir Suppl (Wien) 2011; 108: 17-21
  • 15 Wilson DH, Harbaugh R. Microsurgical and standard removal of the protruded lumbar disc: a comparative study. Neurosurgery 1981; 8 (04) 422-427
  • 16 Xu H, Liu X, Liu G, Zhao J, Fu Q, Xu B. Learning curve of full-endoscopic technique through interlaminar approach for L5/S1 disk herniations. Cell Biochem Biophys 2014; 70 (02) 1069-1074
  • 17 Riesenburger RI, David CA. Lumbar microdiscectomy and microendoscopic discectomy. Minim Invasive Ther Allied Technol 2006; 15 (05) 267-270
  • 18 Overdevest GM, Peul WC, Brand R. Leiden-The Hague Spine Intervention Prognostic Study Group. et al. Tubular discectomy versus conventional microdiscectomy for the treatment of lumbar disc herniation: long-term results of a randomised controlled trial. J Neurol Neurosurg Psychiatry 2017; 88 (12) 1008-1016
  • 19 Chotigavanichaya C, Korwutthikulrangsri E, Suratkarndawadee S. et al. Minimally invasive lumbar discectomy with the tubular retractor system: 4–7 years follow-up. J Med Assoc Thai 2012; 95: 82-86
  • 20 Kunert P, Kowalczyk P, Marchel A. Minimally invasive microscopically assisted lumbar discectomy using the METRx X-Tube system. Neurol Neurochir Pol 2010; 44 (06) 554-559
  • 21 Silvers HR. Microsurgical versus standard lumbar discectomy. Neurosurgery 1988; 22 (05) 837-841
  • 22 Arts MP, Brand R, van den Akker ME, Koes BW, Bartels RH, Peul WC. Leiden-The Hague Spine Intervention Prognostic Study Group (SIPS). Tubular diskectomy vs conventional microdiskectomy for sciatica: a randomized controlled trial. JAMA 2009; 302 (02) 149-158
  • 23 Arts MP, Brand R, van den Akker ME. et al. Tubular diskectomy vs conventional microdiskectomy for the treatment of lumbar disk herniation: 2-year results of a double-blind randomized controlled trial. Neurosurgery 2011; a 69 (01) 135-144, discussion 144
  • 24 Arts M, Brand R, van der Kallen B, Lycklama à Nijeholt G, Peul W. Does minimally invasive lumbar disc surgery result in less muscle injury than conventional surgery? A randomized controlled trial. Eur Spine J 2011; 20 (01) 51-57
  • 25 Ryang YM, Oertel MF, Mayfrank L, Gilsbach JM, Rohde V. Standard open microdiscectomy versus minimal access trocar microdiscectomy: results of a prospective randomized study. Neurosurgery 2008; 62 (01) 174-181 , discussion 181–182
  • 26 Li X, Chang H, Meng X. Tubular microscopes discectomy versus conventional microdiscectomy for treating lumbar disk herniation: systematic review and meta-analysis. Medicine (Baltimore) 2018; 97 (05) e9807
  • 27 Rasouli MR, Rahimi-Movaghar V, Shokraneh F, Moradi-Lakeh M, Chou R. Minimally invasive discectomy versus microdiscectomy/open discectomy for symptomatic lumbar disc herniation. Cochrane Database Syst Rev 2014; 9 (09) CD010328
  • 28 Cahill KS, Levi AD, Cummock MD, Liao W, Wang MY. A comparison of acute hospital charges after tubular versus open microdiskectomy. World Neurosurg 2013; 80 (1–2): 208-212
  • 29 Bhatia PS, Chhabra HS, Mohapatra B, Nanda A, Sangodimath G, Kaul R. Microdiscectomy or tubular discectomy: is any of them a better option for management of lumbar disc prolapse. J Craniovertebr Junction Spine 2016; 7 (03) 146-152
  • 30 Perez-Cruet MJ, Foley KT, Isaacs RE. et al. Microendoscopic lumbar discectomy: technical note. Neurosurgery 2002; 51 (05) S129-S136
  • 31 Atlas SJ, Tosteson TD, Blood EA, Skinner JS, Pransky GS, Weinstein JN. The impact of workers' compensation on outcomes of surgical and nonoperative therapy for patients with a lumbar disc herniation: SPORT. Spine 2010; 35 (01) 89-97
  • 32 Mayer T, McMahon MJ, Gatchel RJ, Sparks B, Wright A, Pegues P. Socioeconomic outcomes of combined spine surgery and functional restoration in workers' compensation spinal disorders with matched controls. Spine 1998; 23 (05) 598-605 , discussion 606