Transforaminal Endoscopic Lumbar Diskectomy versus Open Microdiskectomy for Symptomatic Lumbar Disk Herniation: A Comparative Cohort Study on Costs and Long-Term Outcomes

Abstract

Background Transforaminal endoscopic lumbar diskectomy (TELD) is considered an effective treatment for lumbar disk herniation (LDH). There is a paucity of studies comparing in detail the costs and long-term clinical outcomes of TELD and open microdiskectomy (MD), especially in developing countries. Thus, we sought to provide a multidimensional insight into this matter by comparing the direct costs and long-term outcomes of TELD with those of MD.

Methods The electronic health records of 434 patients with LDH who underwent either TELD or MD were collected from February 2011 to October 2014. Within a 7-year follow-up period, 412 patients, comprising 203 patients treated with TELD and 209 patients treated with MD, were fully evaluated. Patient characteristics, operative time, intraoperative blood loss (IBL), postoperative hospital stay, time to return to work (RTW), perioperative complications, and direct costs were collected. Clinical outcomes were assessed using the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and modified MacNab criteria.

Results The postoperative ODI and VAS scores improved significantly in both groups (p < 0.001). In accordance with the modified MacNab criteria, the rate of excellent and good outcomes was 88.67 and 88.03% in the TELD and MD groups, respectively. There were no significant differences between the groups in the clinical outcomes and perioperative complications. However, IBL, hospital stay, and RTW were significantly reduced in the TELD group (p < 0.05). Twenty-one cases in the TELD group and nine in the MD group underwent reoperation due to recurrence (p < 0.05). Total inpatient cost per patient was $1,596 in the TELD group and $1,990 in the MD group (p < 0.05).

Conclusion TELD for the treatment of symptomatic LDH could be an affordable strategy, providing certain advantages of minimally invasive procedures such as shorter hospital stay and earlier recovery along with comparable clinical outcomes to the conventional surgical method.

Keywords

lumbar disk herniation - transforaminal endoscopic lumbar diskectomy - microdiskectomy - long-term outcomes - costs

Publikationsverlauf

Eingereicht: 17. Februar 2023

Angenommen: 14. August 2023

Artikel online veröffentlicht:
25. Oktober 2023

• References

• 1 Ahn S-S, Kim S-H, Kim D-W, Lee B-H. Comparison of outcomes of percutaneous endoscopic lumbar discectomy and open lumbar microdiscectomy for young adults: a retrospective matched cohort study. World Neurosurg 2016; 86: 250-258
• 2 Saghebdoust S, Shafagh SG, Pak N. et al. Role of percutaneous laser disc decompression in patients with lumbar disc herniation on pain relief: a quasi-experimental pilot study. Galen Med J 2022; 11: e2382-e2382
• 3 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; (09) CD010328
• 4 Schubert M, Hoogland T. Endoscopic transforaminal nucleotomy with foraminoplasty for lumbar disk herniation. Oper Orthop Traumatol 2005; 17 (06) 641-661
• 5 Hijikata S. Percutaneous nucleotomy. A new concept technique and 12 years' experience. Clin Orthop Relat Res 1989; (238) 9-23
• 6 Schreiber A, Suezawa Y. Transdiscoscopic percutaneous nucleotomy in disk herniation. Orthop Rev 1986; 15 (01) 35-38
• 7 Onik G, Maroon J, Helms C. et al. Automated percutaneous diskectomy: initial patient experience. Work in progress. Radiology 1987; 162 (1, Pt 1): 129-132
• 8 Yeung A. Spinal endoscopy with a multichannel, continuous irrigation discoscope with integrated inflow and outflow ports. Poster Presentation: Fourth International Meeting on Advanced Spine Techniques; July 10–13, 1997; Bermuda
• 9 Gu Y-T, Cui Z, Shao H-W, Ye Y, Gu A-Q. Percutaneous transforaminal endoscopic surgery (PTES) for symptomatic lumbar disc herniation: a surgical technique, outcome, and complications in 209 consecutive cases. J Orthop Surg Res 2017; 12 (01) 1-13
• 10 Yeung AT, Tsou PM. Posterolateral endoscopic excision for lumbar disc herniation: Surgical technique, outcome, and complications in 307 consecutive cases. Spine 2002; 27 (07) 722-731
• 11 Hoogland T. Transforaminal endoscopic discectomy with foraminoplasty for lumbar disc herniation. Surg Tech Orthop Traumatol 2003; 40 (40) 55-120
• 12 Hoogland T, Schubert M, Miklitz B, Ramirez A. Transforaminal posterolateral endoscopic discectomy with or without the combination of a low-dose chymopapain: a prospective randomized study in 280 consecutive cases. Spine (Phila Pa 1976) 2006; 31 (24) E890-E897
• 13 Hoogland T, van den Brekel-Dijkstra K, Schubert M, Miklitz B. Endoscopic transforaminal discectomy for recurrent lumbar disc herniation: a prospective, cohort evaluation of 262 consecutive cases. Spine 2008; 33 (09) 973-978
• 14 Chen Z, Zhang L, Dong J. et al. Percutaneous transforaminal endoscopic discectomy compared with microendoscopic discectomy for lumbar disc herniation: 1-year results of an ongoing randomized controlled trial. J Neurosurg Spine 2018; 28 (03) 300-310
• 15 Mysliwiec LW, Cholewicki J, Winkelpleck MD, Eis GP. MSU classification for herniated lumbar discs on MRI: toward developing objective criteria for surgical selection. Eur Spine J 2010; 19 (07) 1087-1093
• 16 Gadjradj PS, Broulikova HM, van Dongen JM. et al. Cost-effectiveness of full endoscopic versus open discectomy for sciatica. Br J Sports Med 2022; 56 (18) 1018-1025
• 17 Seiger A, Gadjradj PS, Harhangi BS. et al. PTED study: design of a non-inferiority, randomised controlled trial to compare the effectiveness and cost-effectiveness of percutaneous transforaminal endoscopic discectomy (PTED) versus open microdiscectomy for patients with a symptomatic lumbar disc herniation. BMJ Open 2017; 7 (12) e018230
• 18 Hees HL, Nieuwenhuijsen K, Koeter MW, Bültmann U, Schene AH. Towards a new definition of return-to-work outcomes in common mental disorders from a multi-stakeholder perspective. PLoS One 2012; 7 (06) e39947
• 19 Steenstra IA, Lee H, de Vroome EM, Busse JW, Hogg-Johnson SJ. Comparing current definitions of return to work: a measurement approach. J Occup Rehabil 2012; 22 (03) 394-400
• 20 Saghebdoust S, Dayyani M, Rouhbakhsh Zahmatkesh MR, Abbasi B, Soltani G, Zare R. Launching awake craniotomy technique in a resource-limited center: new insights into the patient experience, costs, and long-term outcomes and a narrative review of the literature. World Neurosurg 2022; 168: 246-257.e4
• 21 Nellensteijn J, Ostelo R, Bartels R, Peul W, van Royen B, van Tulder M. Transforaminal endoscopic surgery for symptomatic lumbar disc herniations: a systematic review of the literature. Eur Spine J 2010; 19 (02) 181-204
• 22 Liu X, Yuan S, Tian Y. et al. Comparison of percutaneous endoscopic transforaminal discectomy, microendoscopic discectomy, and microdiscectomy for symptomatic lumbar disc herniation: minimum 2-year follow-up results. J Neurosurg Spine 2018; 28 (03) 317-325
• 23 Gempt J, Jonek M, Ringel F, Preuss A, Wolf P, Ryang Y. Long-term follow-up of standard microdiscectomy versus minimal access surgery for lumbar disc herniations. Acta Neurochir (Wien) 2013; 155 (12) 2333-2338
• 24 Eun SS, Lee SH, Sabal LA. Long-term follow-up results of percutaneous endoscopic lumbar discectomy. Pain Physician 2016; 19 (08) E1161-E1166
• 25 Gibson JNA, Subramanian AS, Scott CEH. A randomised controlled trial of transforaminal endoscopic discectomy vs microdiscectomy. Eur Spine J 2017; 26 (03) 847-856
• 26 Ahn Y, Lee SG, Son S, Keum HJ. Transforaminal endoscopic lumbar discectomy versus open lumbar microdiscectomy: a comparative cohort study with a 5-year follow-up. Pain Physician 2019; 22 (03) 295-304
• 27 Li X, Bai J, Hong Y. et al. Minimum seven-year follow-up outcomes of percutaneous endoscopic lumbar discectomy for lumbar degenerative disease. Int J Gen Med 2021; 14: 779-785
• 28 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 (Phila Pa 1976) 2008; 33 (09) 931-939
• 29 Lee DY, Shim CS, Ahn Y, Choi Y-G, Kim HJ, Lee S-H. Comparison of percutaneous endoscopic lumbar discectomy and open lumbar microdiscectomy for recurrent disc herniation. J Korean Neurosurg Soc 2009; 46 (06) 515-521
• 30 Li Z, Zhang C, Chen W. et al. Percutaneous endoscopic transforaminal discectomy versus conventional open lumbar discectomy for upper lumbar disc herniation: a comparative cohort study. BioMed Res Int 2020; 2020: 1852070
• 31 Ahn Y, Lee HY, Lee S-H, Lee JH. Dural tears in percutaneous endoscopic lumbar discectomy. Eur Spine J 2011; 20 (01) 58-64
• 32 Sencer A, Yorukoglu AG, Akcakaya MO. et al. Fully endoscopic interlaminar and transforaminal lumbar discectomy: short-term clinical results of 163 surgically treated patients. World Neurosurg 2014; 82 (05) 884-890
• 33 Mayer HM, Brock M. Percutaneous endoscopic discectomy: surgical technique and preliminary results compared to microsurgical discectomy. J Neurosurg 1993; 78 (02) 216-225
• 34 Ahn Y, Lee S-H, Park W-M, Lee H-Y, Shin S-W, Kang H-Y. Percutaneous endoscopic lumbar discectomy for recurrent disc herniation: surgical technique, outcome, and prognostic factors of 43 consecutive cases. Spine 2004; 29 (16) E326-E332
• 35 Lurie JD, Tosteson TD, Tosteson AN. et al. Surgical versus nonoperative treatment for lumbar disc herniation: eight-year results for the spine patient outcomes research trial. Spine 2014; 39 (01) 3-16
• 36 Krappel F, Schmitz R, Bauer E, Harland U. Offene oder endoskopische Nukleotomie-Ergebnisse einer kontrollierten klinischen Studie mit unabhangiger Nachuntersuchung, MRT und unter besonderer Berucksichtigung der Kosten-Nutzen-Relation. Orthop Prax 2001; 37 (03) 164-169
• 37 Pan Z, Ha Y, Yi S, Cao K. Efficacy of transforaminal endoscopic spine system (TESSYS) technique in treating lumbar disc herniation. Med Sci Monit 2016; 22: 530-539