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Spine Apr 2021Systematic review and meta-analysis. (Comparative Study)
Comparative Study Meta-Analysis
STUDY DESIGN
Systematic review and meta-analysis.
OBJECTIVE
To give a systematic overview of effectiveness of percutaneous transforaminal endoscopic discectomy (PTED) compared with open microdiscectomy (OM) in the treatment of lumbar disk herniation (LDH).
SUMMARY OF BACKGROUND DATA
The current standard procedure for the treatment of sciatica caused by LDH, is OM. PTED is an alternative surgical technique which is thought to be less invasive. It is unclear if PTED has comparable outcomes compared with OM.
METHODS
Multiple online databases were systematically searched up to April 2020 for randomized controlled trials and prospective studies comparing PTED with OM for LDH. Primary outcomes were leg pain and functional status. Pooled effect estimates were calculated for the primary outcomes only and presented as standard mean differences (SMD) with their 95% confidence intervals (CI) at short (1-day postoperative), intermediate (3-6 months), and long-term (12 months).
RESULTS
We identified 2276 citations, of which eventually 14 studies were included. There was substantial heterogeneity in effects on leg pain at short term. There is moderate quality evidence suggesting no difference in leg pain at intermediate (SMD 0.05, 95% CI -0.10-0.21) and long-term follow-up (SMD 0.11, 95% CI -0.30-0.53). Only one study measured functional status at short-term and reported no differences. There is moderate quality evidence suggesting no difference in functional status at intermediate (SMD -0.09, 95% CI -0.24-0.07) and long-term (SMD -0.11, 95% CI -0.45-0.24).
CONCLUSION
There is moderate quality evidence suggesting no difference in leg pain or functional status at intermediate and long-term follow-up between PTED and OM in the treatment of LDH. High quality, robust studies reporting on clinical outcomes and cost-effectiveness on the long term are lacking.Level of Evidence: 2.
Topics: Cost-Benefit Analysis; Diskectomy, Percutaneous; Endoscopy; Humans; Intervertebral Disc Degeneration; Intervertebral Disc Displacement; Lumbar Vertebrae; Microsurgery; Pain Measurement; Prospective Studies; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 33290374
DOI: 10.1097/BRS.0000000000003843 -
Medicine Feb 2019Systematic review with network meta-analysis.
STUDY DESIGN
Systematic review with network meta-analysis.
OBJECTIVE
To compare patient outcomes of lumbar discectomy with bone-anchored annular closure (LD + AC), lumbar discectomy (LD), and continuing conservative care (CC) for treatment of lumbar disc herniation refractory to initial conservative management.
SUMMARY OF BACKGROUND DATA
Several treatment options are available to patients with refractory symptoms of lumbar disc herniation, but their comparative efficacy is unclear.
METHODS
A systematic review was performed to compare efficacy of LD + AC, LD, and CC for treatment of lumbar disc herniation. Outcomes included leg pain, back pain, disability (each reported on a 0-100 scale), reherniation, and reoperation. Data were analyzed using random effects network meta-analysis.
RESULTS
This review included 14 comparative studies (8 randomized) involving 3947 patients-11 studies of LD versus CC (3232 patients), 3 studies of LD + AC versus LD (715 patients), and no studies of LD + AC versus CC. LD was more effective than CC in reducing leg pain (mean difference [MD] -10, P < .001) and back pain (MD -7, P < .001). LD + AC was more effective than LD in reducing risk of reherniation (odds ratio 0.38, P < .001) and reoperation (odds ratio 0.33, P < .001). There was indirect evidence that LD + AC was more effective than CC in reducing leg pain (MD -25, P = .003), back pain (MD -20, P = .02), and disability (MD -13, P = .02) although the treatment effect was smaller in randomized trials.
CONCLUSIONS
Results of a network meta-analysis show LD is more effective than CC in alleviating symptoms of lumbar disc herniation refractory to initial conservative management. Further, LD + AC lowers risk of reherniation and reoperation versus LD and may improve patient symptoms more than CC.
Topics: Age Factors; Bone-Anchored Prosthesis; Conservative Treatment; Disability Evaluation; Diskectomy; Humans; Intervertebral Disc Displacement; Lumbar Vertebrae; Network Meta-Analysis; Pain; Reoperation; Sex Factors
PubMed: 30762743
DOI: 10.1097/MD.0000000000014410 -
Global Spine Journal Feb 2017Systematic review and meta-analysis. (Review)
Review
STUDY DESIGN
Systematic review and meta-analysis.
OBJECTIVE
Anterior cervical diskectomy and fusion (ACDF) is an effective surgical option for patients with cervical radiculopathy, myelopathy, or deformity. Although ACDF is generally safe, dysphagia is a common complication. Despite its high incidence, prolonged postoperative dysphagia is poorly understood; its etiology remains relatively unknown, and its risk factors are widely debated.
METHODS
We searched MEDLINE, Scopus, Web of Science, and Embase for studies reporting complications for cervical diskectomy with plating. We recorded dysphagia events from all included studies and calculated effect summary values, 95% confidence intervals (CIs), Q values, and values.
RESULTS
Of the 7,780 retrieved articles, 14 met inclusion criteria. The overall dysphagia rate was 8.5% (95% CI 5.7 to 11.3%). The rate of moderate or severe dysphagia was 4.4% (0.4 to 8.4%). Follow-up times of <12, 12 to 24, and >24 months reported rates of 19.9% (6.0 to 33.7%), 7.0% (5.2 to 8.7%), and 7.6% (1.4 to 13.8%), respectively. Studies utilizing the Bazaz Dysphagia Score resulted in an increase in dysphagia diagnosis relative to studies with no outlined criteria (19.8%, 5.9 to 33.7% and 6.9%, 3.7 to 10.0%, respectively), indicating that the criteria used for dysphagia identification are critical. There was no difference in dysphagia rate with the use of autograft versus allograft.
CONCLUSIONS
This review represents a comprehensive estimation of the actual incidence of dysphagia across a heterogeneous group of surgeons, patients, and criteria. The classification scheme for dysphagia varied significantly within the literature. To ensure its diagnosis and identification, we recommend the use of a standardized, well-outlined method for dysphagia diagnosis.
PubMed: 28451514
DOI: 10.1055/s-0036-1583944 -
World Neurosurgery Oct 2023There are no systematic evidence-based medical data on the complications of endoscopic cervical spinal surgery. This narrative analysis compiled data from various... (Review)
Review
BACKGROUND
There are no systematic evidence-based medical data on the complications of endoscopic cervical spinal surgery. This narrative analysis compiled data from various studies that examined endoscopic complications, such as cervical disc herniation and foraminal stenosis. This study aimed to investigate the efficacy and safety of endoscopic surgery in cervical radiculopathy.
METHODS
We searched the PubMed/MEDLINE databases to identify articles on endoscopic spinal surgery, and keywords were set as "endoscopic cervical spinal surgery", "endoscopic cervical discectomy", "endoscopic cervical foraminotomy", and "percutaneous endoscopic cervical discectomy". We analyzed the evidence level and classified the prescribed complications according to the literature. Endoscopic cervical surgery was divided into three categories: full endoscopic anterior, endoscopic posterior, and unilateral biportal approaches. We excluded duplicate publications, studies without full text, studies without complications or incomplete information, and studies that did not provide the necessary data for extraction, animal experiments, or reviews.
RESULTS
Difficulties in swallowing, hematoma, and hoarseness are common complications associated with the anterior cervical approach. In contrast, complications of the posterior approach include nerve root injury, hematoma, and dysesthesia. However, endoscopic cervical spinal surgery, including the full endoscopic anterior, posterior, and unilateral biportal approaches, is a safe and effective treatment for cervical radiculopathy.
CONCLUSIONS
Complications of full endoscopic cervical spinal surgery differ significantly depending on the anterior and posterior approaches. In the anterior approach, swallowing difficulty, recurrent disc, hematoma, and dysphonia are the common complications. In contrast, transient dysesthesia, dural tears, upper limb motor deficits, and persistent arm pain are commonly reported with the posterior approach.
Topics: Humans; Radiculopathy; Paresthesia; Cervical Vertebrae; Endoscopy; Intervertebral Disc Displacement; Diskectomy; Hematoma; Treatment Outcome; Retrospective Studies
PubMed: 37479028
DOI: 10.1016/j.wneu.2023.07.058 -
Spine Apr 2023A systematic review of the literature to develop an algorithm formulated by key opinion leaders.
STUDY DESIGN
A systematic review of the literature to develop an algorithm formulated by key opinion leaders.
OBJECTIVE
This study aimed to analyze currently available data and propose a decision-making algorithm for full-endoscopic lumbar discectomy for treating lumbar disc herniation (LDH) to help surgeons choose the most appropriate approach [transforaminal endoscopic lumbar discectomy (TELD) or interlaminar endoscopic lumbar discectomy (IELD)] for patients.
SUMMARY OF BACKGROUND DATA
Full-endoscopic discectomy has gained popularity in recent decades. To our knowledge, an algorithm for choosing the proper surgical approach has never been proposed.
MATERIALS AND METHODS
A systematic review of the literature using PubMed and MeSH terms was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Patient samples included patients with LDH treated with full-endoscopic discectomy. The inclusion criteria were interventional research (randomized and nonrandomized trials) and observation research (cohort, case-control, case series). Exclusion criteria were case series and technical reports. The criteria used for selecting patients were grouped and analyzed. Then, an algorithm was generated based on these findings with support and reconfirmation from key expert opinions. Data on overall complications were collected. Outcome measures included zone of herniation, level of herniation, and approach (TELD or IELD).
RESULTS
In total, 474 articles met the initial screening criteria. The detailed analysis identified the 80 best-matching articles; after applying the inclusion and exclusion criteria, 53 articles remained for this review.
CONCLUSIONS
The proposed algorithm suggests a TELD for LDH located in the foraminal or extraforaminal zones at upper and lower levels and for central and subarticular discs at the upper levels considering the anatomic foraminal features and the craniocaudal pathology location. An IELD is preferred for LDH in the central or subarticular zones at L4/L5 and L5/S1, especially if a high iliac crest or high-grade migration is found.
Topics: Humans; Diskectomy, Percutaneous; Lumbar Vertebrae; Diskectomy; Intervertebral Disc Displacement; Endoscopy; Treatment Outcome; Retrospective Studies
PubMed: 36745468
DOI: 10.1097/BRS.0000000000004589 -
The Spine Journal : Official Journal of... Apr 2023Previous low-quality evidence has suggested preoperative Modic changes (MC) showed a trend toward less improvement in low back pain in patients with lumbar disc... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND CONTEXT
Previous low-quality evidence has suggested preoperative Modic changes (MC) showed a trend toward less improvement in low back pain in patients with lumbar disc herniation (LDH) undergoing discectomy. However, a recent meta-analysis concluded that the presence of preoperative MC did not significantly impact clinical outcomes following lumbar discectomy.
PURPOSE
To compare low back pain and functional outcomes of patients after discectomy for LDH with preoperative MC.
STUDY DESIGN
Systematic review and meta-analysis of cohort studies.
METHODS
This comprehensive systematic review and meta-analysis used English-language articles identified through searches using Pubmed, Web of Science, Embase, and Cochrane library until August 2022. The included studies identified publications that concentrated on the patients suffering from LDH with different preoperative MCs treated by discectomy. The Visual Analogue Scale (VAS) and the Oswestry Disability Index (ODI) were the two main metrics to evaluate outcomes.
RESULTS
A series of 2,299 LDH patients with a definitive type of MC were included in four retrospective and five prospective studies. Overall, there is moderate to high quality evidence suggesting no significant difference between normal and MC groups for pain outcomes as well as normal and Modic type 2 groups in terms of pain or functional outcomes at one or two-year follow up. There are less functional outcomes in LDH patients with preoperative MC compared with no MC at 2-year follow up and showed no significant difference at 1-year follow-up. However, above all results may due to heterogeneity. Subgroup analysis revealed that only Modic type 1 showed statistically lower functional scores (mean difference in ODI scores range from 0 to 100) compared with Modic type 2 or compared with no MC at 2-year follow-up and showed no significant difference at 1-year follow-up (MC1 vs. MC0, p=.24, MD= -2.70; 95% CI, -7.15 to 1.76 for 1-year;p<.00001, MD= -7.92; 95% CI, -11.19 to -4.66 for 2 years. MC1 vs. MC2, p=.58, MD= -1.29; 95% CI, -5.83 to 3.25 for 1-year;p<.0001, MD= -6.77; 95% CI, -9.94 to -3.61 for 2 years).
CONCLUSIONS
These data suggest LDH patients with or without preoperative MCs show a similar improvement of low back pain at 1 and 2-year follow-up and functional scores after discectomy at one-year follow-up. LDH patients with preoperative Modic type 1 are associated with worse functional status after discectomy at 2-year follow-up. However, high-quality randomized controlled trials and prospective cohort studies which focus on analyzing the risk and confounding factors are lacking.
Topics: Humans; Intervertebral Disc Displacement; Low Back Pain; Prospective Studies; Retrospective Studies; Lumbar Vertebrae; Diskectomy; Treatment Outcome
PubMed: 36328303
DOI: 10.1016/j.spinee.2022.10.008 -
The Spine Journal : Official Journal of... Feb 2016Cervical arthroplasty is an increasingly popular alternative for the treatment of cervical radiculopathy and myelopathy. This technique preserves motion at the index and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND CONTEXT
Cervical arthroplasty is an increasingly popular alternative for the treatment of cervical radiculopathy and myelopathy. This technique preserves motion at the index and adjacent disc levels, avoiding the restraints of fusion and potentially minimizing adjacent segment pathology onset during the postoperative period.
PURPOSE
This study aimed to identify all prospective studies reporting adjacent segment pathology rates for cervical arthroplasty.
STUDY DESIGN/SETTING
Systematic review and meta-analysis were carried out.
PATIENT SAMPLE
Studies reporting adjacent segment degeneration (ASDegeneration) and adjacent segment disease (ASDisease) rates in patients who underwent cervical arthroplasty comprised the patient sample.
OUTCOME MEASURES
Outcomes of interest included reported ASDegeneration and ASDisease events after cervical arthroplasty.
METHODS
We conducted a MEDLINE, SCOPUS, and Web of Science search for studies reporting ASDegeneration or ASDisease following cervical arthroplasty. A meta-analysis was performed to calculate effect summary values, 95% confidence intervals (CIs), Q values, and I(2) values. Forest plots were constructed for each analysis group.
RESULTS
Of the 1,891 retrieved articles, 32 met inclusion criteria. The patient incidence of ASDegeneration and ASDisease was 8.3% (95% CI 3.8%-12.7%) and 0.9% (95% CI 0.1%-1.7%), respectively. The rate of ASDegeneration and ASDisease at individual levels was 10.5% (95% CI 6.1%-14.9%) and 0.2% (95% CI -0.1% to 0.5%), respectively. Studies following patients for 12-24 months reported a 5.1% (95% CI 2.1%-8.1%) incidence of ASDegeneration and 0.2% (95% CI 0.1%-0.2%) incidence of ASDisease. Conversely, studies following patients for greater than 24 months reported a 16.6% (5.8%-27.4%) incidence of ASDegeneration and 2.6% (95% CI 1.0%-4.2%) of ASDisease. This identified a statistically significant increase in ASDisease diagnosis with lengthier follow-up. Additionally, 1- and 2-level procedures resulted in a 7.4% (95% CI 3.3%-11.4%) and15.6% (95 CI-9.2% to 40.4%) incidence of ASDegeneration, respectively. Although there was an 8.2% increase in ASDegeneration following 2-level operations (relative to 1-level), it did not reach statistical significance. We were unable to analyze ASDisease incidence following 2-level arthroplasty (too few cases), but 1-level operations resulted in an ASDisease incidence of 0.8% (95% CI 0.1%-1.5%).
CONCLUSIONS
This review represents a comprehensive estimation of the actual incidence of ASDegeneration and ASDisease across a heterogeneous group of surgeons, patients, and arthroplasty techniques. Our investigation should serve as a framework for individual surgeons to understand the impact of various cervical arthroplasty techniques, follow-up duration, and surgical levels on the incidence of ASDegeneration and ASDisease during the postoperative period.
Topics: Arthroplasty; Cervical Vertebrae; Diskectomy; Female; Humans; Intervertebral Disc Degeneration; Male; Spinal Fusion
PubMed: 26515401
DOI: 10.1016/j.spinee.2015.10.032 -
Journal of Orthopaedic Surgery and... Dec 2022Since there are currently no systematic evidence-based medical data on the efficacy and safety of PECD, this meta-analysis pooled data from studies that reported the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Since there are currently no systematic evidence-based medical data on the efficacy and safety of PECD, this meta-analysis pooled data from studies that reported the efficacy or safety of PECD for cervical disc herniation to examine the efficacy, recurrence and safety of using PECD to treat cervical disc herniation.
METHODS
We searched the PubMed, EMBASE and Cochrane Library databases for studies published from inception to July 2022. Nine nonrandomized controlled trials (non-RCTs) that reported the efficacy or safety of percutaneous endoscopic cervical discectomy for cervical disc herniation were included. We excluded duplicate publications, studies without full text, studies with incomplete information, studies that did not enable us to conduct data extraction, animal experiments and reviews. STATA 15.1 software was used to analyse the data.
RESULTS
The proportions of excellent and good treatment results after PECD for CDH were 39% (95% CI: 31-48%) and 47% (95% CI: 34-59%), respectively. The pooled results showed that the VAS scores at 1 week post-operatively (SMD = -2.55, 95% CI: - 3.25 to - 1.85) and at the last follow-up (SMD = - 4.30, 95% CI: - 5.61 to - 3.00) after PECD for cervical disc herniation were significantly lower than the pre-operative scores. The recurrence rate of neck pain and the incidence of adverse events after PECD for cervical disc herniation were 3% (95% CI: 1-6%) and 5% (95% CI: 2-9%), respectively. Additionally, pooled results show that the operative time (SMD = - 3.22, 95% CI: - 5.21 to - 1.43) and hospital stay (SMD = - 1.75, 95% CI: - 2.67to - 0.84) were all significantly lower for PECD than for ACDF. The pooled results also showed that the proportion of excellent treatment results was significantly higher for PECD than for ACDF (OR = 2.29, 95% CI: 1.06-4.96).
CONCLUSION
PECD has a high success rate in the treatment of CHD and can relieve neck pain, and the recurrence rate and the incidence of adverse events are low. In addition, compared with ACDF, PECD has a higher rate of excellent outcomes and a lower operative time and hospital stay. PECD may be a better option for treating CHD.
Topics: Animals; Humans; Intervertebral Disc Displacement; Neck Pain; Diskectomy, Percutaneous; Diskectomy; Endoscopy
PubMed: 36456964
DOI: 10.1186/s13018-022-03365-1 -
Neurosurgical Focus Oct 2015OBJECT Lumbar microdiscectomy and its various minimally invasive surgical techniques are seeing increasing popularity, but a systematic review of their associated... (Meta-Analysis)
Meta-Analysis Review
OBJECT Lumbar microdiscectomy and its various minimally invasive surgical techniques are seeing increasing popularity, but a systematic review of their associated complications has yet to be performed. The authors sought to identify all prospective clinical studies reporting complications associated with lumbar open microdiscectomy, microendoscopic discectomy (MED), and percutaneous microdiscectomy. METHODS The authors conducted MEDLINE, Scopus, Web of Science, and Embase database searches for randomized controlled trials and prospective cohort studies reporting complications associated with open, microendoscopic, or percutaneous lumbar microdiscectomy. Studies with fewer than 10 patients and published before 1990 were excluded. Overall and interstudy median complication rates were calculated for each surgical technique. The authors also performed a meta-analysis of the reported complications to assess statistical significance across the various surgical techniques. RESULTS Of 9504 articles retrieved from the databases, 42 met inclusion criteria. Most studies screened were retrospective case series, limiting the number of studies that could be included. A total of 9 complication types were identified in the included studies, and these were analyzed across each of the surgical techniques. The rates of any complication across the included studies were 12.5%, 13.3%, and 10.8% for open, MED, and percutaneous microdiscectomy, respectively. New or worsening neurological deficit arose in 1.3%, 3.0%, and 1.6% of patients, while direct nerve root injury occurred at rates of 2.6%, 0.9%, and 1.1%, respectively. Hematoma was reported at rates of 0.5%, 1.2%, and 0.6%, respectively. Wound complications (infection, dehiscence, orseroma) occurred at rates of 2.1%, 1.2%, and 0.5%, respectively. The rates of recurrent disc complications were 4.4%, 3.1%, and 3.9%, while reoperation was indicated in 7.1%, 3.7%, and 10.2% of operations, respectively. Meta-analysis calculations revealed a statistically significant higher rate of intraoperative nerve root injury following percutaneous procedures relative to MED. No other significant differences were found. CONCLUSIONS This review highlights complication rates among various microdiscectomy techniques, which likely reflect real-world practice and conceptualization of complications among physicians. This investigation sets the framework for further discussions regarding microdiscectomy options and their associated complications during the informed consent process.
Topics: Diskectomy; Humans; Intervertebral Disc Displacement; Lumbar Vertebrae; Postoperative Complications
PubMed: 26424346
DOI: 10.3171/2015.7.FOCUS15281 -
Spine Apr 2018Systematic review and meta-analysis. (Comparative Study)
Comparative Study Meta-Analysis Review
STUDY DESIGN
Systematic review and meta-analysis.
OBJECTIVE
To compare postoperative surgical, radiographic, and patient-reported outcomes following anterior cervical discectomy and fusion (ACDF) with and without plate fixation.
SUMMARY OF BACKGROUND DATA
ACDF has evolved significantly over the years, including the placement of an anterior plate construct. Although promoting bony osseo-integration at the fusion site, there are a number of plate-related complications that can arise. The non-plating approach is less invasive, however, greater rates of cage subsidence have been associated with this model.
METHODS
We performed an electronic literature search for human studies that directly compared ACDF with and without anterior plate fixation. Outcomes of interest comprised of postoperative dysphagia, fusion success, and cage subsidence as well as patient reported outcomes, including the Neck Disability Index (NDI) scores and Visual Analog Scale (VAS) for both neck and arm pain.
RESULTS
A total of 15 studies (12 observational and 3 randomized controlled trials) and 893 patients (57% males) were included. Overall, ACDF with plate fixation was associated with significantly higher vertebral fusion rates (odds ratio [OR] 1.98; 95% confidence interval [CI] 1.16-3.37), lower subsidence rates (odds ratio [OR] 0.31, 95% CI 0.18-0.52), and more favorable VAS-neck pain scores at last follow-up (mean difference [MD] 0.59, 95% CI -0.78 to -0.41). Conversely, ACDF procedures without plate fixation had marginally better long-term VAS-arm pain scores (mean difference [MD] 0.2, 95% CI 0.04-0.36). No difference was found with regards to dysphagia (OR 1.21, 95% CI, 0.57-2.56) and NDI (MD 0.06, 95% C.I -0.54 to 0.42).
CONCLUSION
Available evidence, although limited, suggests superior surgical outcomes in ACDF procedures with anterior plate fixation (increased fusion, decreased subsidence) and slightly better VAS-neck pain scores at last follow-up. Future longitudinal, multicenter randomized controlled trials should be completed to validate any associations found in this study.
LEVEL OF EVIDENCE
3.
Topics: Aged; Bone Plates; Cervical Vertebrae; Deglutition Disorders; Diskectomy; Female; Humans; Male; Middle Aged; Pain Measurement; Patient Reported Outcome Measures; Spinal Fusion; Treatment Outcome
PubMed: 29016435
DOI: 10.1097/BRS.0000000000002441