Is transforaminal endoscopic discectomy better than open micodiscectomy?

Transforaminal endoscopic surgery for symptomatic lumbar disc herniations: a systematic review of the literature.

Eur Spine J. 2010 Jun;19(6):879-86. Epub 2010 Jan 20.

Nellensteijn J, Ostelo R, Bartels R, Peul W, van Royen B, van Tulder M.

Source

- Amsterdam, The Netherlands.

The study design includes a systematic literature review. The objective of the study was to evaluate the effectiveness of transforaminal endoscopic surgery and to compare this with open microdiscectomy in patients with symptomatic lumbar disc herniations. Transforaminal endoscopic techniques for patients with symptomatic lumbar disc herniations have become increasingly popular. The literature has not yet been systematically reviewed. 

A comprehensive systematic literature search of the MEDLINE and EMBASE databases was performed up to May 2008. Two reviewers independently checked all retrieved titles and abstracts and relevant full text articles for inclusion criteria. Included articles were assessed for quality and outcomes were extracted by the two reviewers independently. One randomized controlled trial, 7 non-randomized controlled trials and 31 observational studies were identified. Studies were heterogeneous regarding patient selection, indications, operation techniques, follow-up period and outcome measures and the methodological quality of these studies was poor. 

The eight trials did not find any statistically significant differences in leg pain reduction between the transforaminal endoscopic surgery group (89%) and the open microdiscectomy group (87%); overall improvement (84 vs. 78%), re-operation rate (6.8 vs. 4.7%) and complication rate (1.5 vs. 1%), respectively.

 In conclusion, current evidence on the effectiveness of transforaminal endoscopic surgery is poor and does not provide valid information to either support or refute using this type of surgery in patients with symptomatic lumbar disc herniation.

 High-quality randomized controlled trials with sufficiently large sample sizes are directly needed to evaluate if transforaminal endoscopic surgery is more effective than open microdiscectomy.

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IORG Spine Update

Role of Caudal Epidural injections in treatment of Lumbar disc herniation and radiculitis?

Spine (Phila Pa 1976). 2011 Nov 1;36(23):1897-905.
Manchikanti L, Singh V, Cash KA, Pampati V, Damron KS, Boswell MV.

A randomized, controlled, double-blind trial of fluoroscopic caudal epidural injections in the treatment of lumbar disc herniation and radiculitis.


Source
*Pain Management Center of Paducah, Paducah, KY †Pain Diagnostics Associates, Niagara, WI ‡Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY.



STUDY DESIGN.: A randomized, controlled, double-blind trial. OBJECTIVE.: To assess the effectiveness of fluoroscopically directed caudal epidural injections in managing chronic low back and lower extremity pain in patients with disc herniation and radiculitis with local anesthetic with or without steroids.

SUMMARY OF BACKGROUND DATA.: The available literature on the effectiveness of epidural injections in managing chronic low back pain secondary to disc herniation is highly variable.

METHODS.: One hundred twenty patients suffering with low back and lower extremity pain with disc herniation and radiculitis were randomized to one of the two groups: group I received caudal epidural injections with an injection of local anesthetic, lidocaine 0.5%, 10 mL; group II patients received caudal epidural injections with 0.5% lidocaine, 9 mL, mixed with 1 mL of steroid.The Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake were utilized with assessment at 3, 6, and 12 months posttreatment.

RESULTS.: The percentage of patients with significant pain relief of 50% or greater and/or improvement in functional status with 50% or more reduction in ODI scores was seen in 70% and 67% in group I and 77% and 75% in group II with average procedures per year of 3.8 ± 1.4 in group I and 3.6 + 1.1 in group II. However, the relief with first and second procedures was significantly higher in the steroid group. The number of injections performed was also higher in local anesthetic group even though overall relief was without any significant difference among the groups. There was no difference among the patients receiving steroids.

CONCLUSION.: Caudal epidural injection with local anesthetic with or without steroids might be effective in patients with disc herniation or radiculitis. The present evidence illustrates potential superiority of steroids compared with local anesthetic at 1-year follow-up.

IORG Spine Update

Is greater lumbar vertebral BMD associated with more disk degeneration? A study using µCT and discography.

Wang Y, Boyd SK, Battié MC, Yasui Y, Videman T.
J Bone Miner Res. 2011 Nov;26(11):2785-91.


It is well documented that osteoarthritis is associated with greater BMD in peripheral extremities. Yet the relationship between vertebral BMD and disk degeneration (DD) remains controversial in the lumbar spine, which may be due largely to the inadequacies of BMD and DD measures.

Aiming to clarify the association between vertebral BMD and adjacent DD, we studied 137 cadaveric lumbar vertebrae and 209 corresponding intervertebral disks from the spines of 48 white men aged 21 to 64 years. DD was evaluated using discography. The vertebrae were scanned using a micro-computed tomography (µCT) system to obtain volumetric BMD for the whole vertebra, the vertebral body, the vertebral body excluding osteophytes, and the vertebral body excluding osteophytes and endplates. A random effects model was used to examine the association between the different definitions of vertebral BMD and adjacent DD.
No significant association was found between the BMD of the whole vertebra and adjacent DD. However, when the posterior elements were excluded, there was a significant association between greater vertebral body BMD and more severe degeneration in the disk cranial to the vertebra. This association remained after further excluding osteophytes and endplates from the vertebral body BMD measurements. Also, a trend of greater BMD of the vertebral body associated with more adjacent DD was evident.
These results clarify the association between vertebral BMD and DD and specifically indicate that it is higher BMD of the vertebral body, not the entire vertebra, that is associated with more severe adjacent DD. This association may be obscured by the posterior elements and is not confounded by osteophytes and endplate sclerosis.
J Bone Miner Res. 2011 Nov;26(11):2785-91.

IORG Spine Update

Vertebroplasty: A miracle for painful vertebral osteoporotic fractures or a clinical illusion……..

Vertebroplasty: A miracle for painful vertebral osteoporotic fractures or a clinical illusion…….. Author – Dr Sushant Ghate MS [Orth],

Assistant professor, Cooper Hospital, Mumbai 

  Preview: Vertebral insufficiency fractures are most common type of fractures occurring in patients with osteoporosis [1]. Nearly two third are asymptomatic and rest one third presents with acute back pain [2]. Usually such patient present with acute back pain and radiographs showing evidence of osteoporotic fracture and are generally considered for vertebral augmentation procedure either vertebroplasty or kyphoplasty on failure of conservative management. But two recent randomized controlled trials performed by Kallmes Et al and Buchbinder Et al has introduced doubts in mind of treating physicians regarding these procedures for relief of pain in vertebral insufficiency fractures [3, 4]. These papers subsequently sparked a lot of controversy and many authors have pointed out limitations and deficiency in designs of these studies. This is a very important factor to analyse, which should be considered before these studies alter our treatment strategy.

Review of literature: Buchbinder et al (2009) performed a multicenter double blind randomized trial in participants having osteoporotic vertebral fractures less than 12 months duration and unhealed as confirmed by MRI, randomly allotting them to undergo vertebroplasty or sham procedure. 35 underwent vertebroplasty and 36 were in placebo group [4]. At 3 months mean reductions in score for pain in vertebroplasty and control group were 2.6+/-2.9 and 1.9+/-3.3 respectively. They concluded that there was no beneficial effect of vertebroplasty in patients having painful osteoporotic vertebral fractures as compared to sham group at 1week, 1 month, 3 month or 6 month after treatment [4]. Kallmes et al (2009) conducted a multicenter trial randomly assigning 131 patients who had one to three painful osteoporotic fractures to undergo vertebroplasty or a simulated procedure without cement (control group) [3].

Use of Bone Morphogenic Proteins in spinal fusion

Bone Morphogenic Proteins and Spinal Fusion:
 By - Dr Prakash Nayak, MS Ortho Editor - Dr Ashok Shyam, MS Ortho

 Research into Bone morphogenetic protein, or BMP, has seen a flurry of events in last decade. They seem to provide a better way to achieve spinal fusion with more success and less complications. An up-to-date review of role of BMPs in spinal fusion is reported below

  SPINAL FUSION.....
 Spinal fusion has always been a challenge. The success of this procedure is limited by morbidity from iliac crest bone graft harvest and a non-union rate that ranges from 10% to 40% [1,2].