Introducing Interlaminar Full-Endoscopic Lumbar Diskectomy: A Critical Analysis of Complications, Recurrence Rates, and Outcome in View of Two Spinal Surgeons' Learning Curves

Abstract

Background and Study Objective Interlaminar full-endoscopic diskectomy is a minimally invasive surgical alternative to microdiskectomy for the treatment of lumbar disk herniation. The authors analyze their surgical results and learning curves during and after the introductory phase of this surgical technique.

Patients and Methods We present a case review of 76 patients operated on using interlaminar full-endoscopic diskectomy. We retrospectively analyzed two spinal surgeons' learning curves in terms of operation time with respect to intraoperative blood loss, conversion rates, complications, infections, length of hospitalization, need for rehabilitation, recurrence rates, pain intensity, and opioid use. Patients' functional status and Health-related Quality of Life were assessed by follow-up questionnaires for 47 patients, using the North American Spine Society Score and the Short Form 12 in addition to long-term pain intensity, work capacity, and patient satisfaction with the operation.

Results A steady state of the learning curve (operation time) of an experienced spinal surgeon was reached after 40 cases. Supervision by a more experienced surgeon can shorten the learning curve. The rate of conversions (10%), complications (5%), and recurrent lumbar disk herniations (28%) did not negatively affect the long-term outcome in patients operated on before and after the learning phase. Patient satisfaction was high.

Conclusions The rate of conversions, complications, and recurrent lumbar disk herniations compared with microdiskectomy combined with the challenging learning curve should be considered before surgeons adopt this procedure. Supervision by an endoscopically experienced spinal surgeon during the introductory phase is highly advisable.

Keywords

full-endoscopic lumbar diskectomy - learning curve - minimally invasive - percutaneous endoscopic lumbar diskectomy - recurrence rate

• References

• 1 Perez-Cruet MJ, Foley KT, Isaacs RE , et al. Microendoscopic lumbar discectomy: technical note. Neurosurgery 2002; 51 (5, Suppl): S129-S136
• 2 Nowitzke AM. Assessment of the learning curve for lumbar microendoscopic discectomy. Neurosurgery 2005; 56 (4) 755-762 ; discussion 755–762
• 3 Teli M, Lovi A, Brayda-Bruno M , et al. Higher risk of dural tears and recurrent herniation with lumbar micro-endoscopic discectomy. Eur Spine J 2010; 19 (3) 443-450
• 4 Rong LM, Xie PG, Shi DH , et al. Spinal surgeons' learning curve for lumbar microendoscopic discectomy: a prospective study of our first 50 and latest 10 cases. Chin Med J (Engl) 2008; 121 (21) 2148-2151
• 5 Ruetten S, Komp M, Merk H, Godolias G. Use of newly developed instruments and endoscopes: full-endoscopic resection of lumbar disc herniations via the interlaminar and lateral transforaminal approach. J Neurosurg Spine 2007; 6 (6) 521-530
• 6 Ruetten S, Komp M, Godolias G. A new full-endoscopic technique for the interlaminar operation of lumbar disc herniations using 6-mm endoscopes: prospective 2-year results of 331 patients. Minim Invasive Neurosurg 2006; 49 (2) 80-87
• 7 Hsu HT, Chang SJ, Yang SS, Chai CL. Learning curve of full-endoscopic lumbar discectomy. Eur Spine J 2013; 22 (4) 727-733
• 8 Kim HS, Park JY. Comparative assessment of different percutaneous endoscopic interlaminar lumbar discectomy (PEID) techniques. Pain Physician 2013; 16 (4) 359-367
• 9 Wang B, Lü G, Liu W, Cheng I, Patel AA. Full-endoscopic interlaminar approach for the surgical treatment of lumbar disc herniation: the causes and prophylaxis of conversion to open. Arch Orthop Trauma Surg 2012; 132 (11) 1531-1538
• 10 Choi KC, Kim JS, Ryu KS, Kang BU, Ahn Y, Lee SH. Percutaneous endoscopic lumbar discectomy for L5-S1 disc herniation: transforaminal versus interlaminar approach. Pain Physician 2013; 16 (6) 547-556
• 11 Wang B, Lü G, Patel AA, Ren P, Cheng I. An evaluation of the learning curve for a complex surgical technique: the full endoscopic interlaminar approach for lumbar disc herniations. Spine J 2011; 11 (2) 122-130
• 12 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 (9) 931-939
• 13 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 (2) 1069-1074
• 14 Yadav YR, Parihar V, Namdev H, Agarwal M, Bhatele PR. Endoscopic interlaminar management of lumbar disc disease. J Neurol Surg A Cent Eur Neurosurg 2013; 74 (2) 77-81
• 15 Pose B, Sangha O, Peters A, Wildner M. Validation of the North American Spine Society Instrument for assessment of health status in patients with chronic backache [in German]. Z Orthop Ihre Grenzgeb 1999; 137 (5) 437-441
• 16 Morfeld M, Kirchberger I, Bullinger M. SF-36. Fragebogen zum Gesundheitszustand. Deutsche Version des Short Form-36 Health Survey. Göttingern, Germany: Hogrefe; 2011
• 17 Klaus B, Strimmer K. Estimation of (local) false discovery rates and higher criticism. Available at: http://strimmerlab.org/software/fdrtool
• 18 R Development Core Team. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing; 2013. Available at: http://www.R-project.org/
• 19 Benzel EC, Orr RD. A steep learning curve is a good thing!. Spine J 2011; 11 (2) 131-132
• 20 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 (5) 884-890
• 21 Casal-Moro R, Castro-Menéndez M, Hernández-Blanco M, Bravo-Ricoy JA, Jorge-Barreiro FJ. Long-term outcome after microendoscopic diskectomy for lumbar disk herniation: a prospective clinical study with a 5-year follow-up. Neurosurgery 2011; 68 (6) 1568-1575 ; discussion 1575
• 22 Stienen MN, Smoll NR, Hildebrandt G, Schaller K, Gautschi OP. Early surgical education of residents is safe for microscopic lumbar disc surgery. Acta Neurochir (Wien) 2014; 156 (6) 1205-1214
• 23 Matsumoto M, Watanabe K, Hosogane N , et al. Recurrence of lumbar disc herniation after microendoscopic discectomy. J Neurol Surg A Cent Eur Neurosurg 2013; 74 (4) 222-227
• 24 Osterman H, Sund R, Seitsalo S, Keskimäki I. Risk of multiple reoperations after lumbar discectomy: a population-based study. Spine 2003; 28 (6) 621-627
• 25 Huang TJ, Hsu RW, Li YY, Cheng CC. Less systemic cytokine response in patients following microendoscopic versus open lumbar discectomy. J Orthop Res 2005; 23 (2) 406-411
• 26 Shin DA, Kim KN, Shin HC, Yoon DH. The efficacy of microendoscopic discectomy in reducing iatrogenic muscle injury. J Neurosurg Spine 2008; 8 (1) 39-43