- *Corresponding Author:
- Yuwei Li
Department of Orthopedic
Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine
No. 18 Yangsu Road, Suzhou 21500, China
|This article was originally published in a special issue, “Therapeutic Perspectives in Biomedical Research and Pharmaceutical Sciences and their Nursing Methods”|
|Indian J Pharm Sci 2021:83(4)Spl issue “90-95”|
This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms
To explore the factors influencing the short-term efficacy of percutaneous transforaminal endoscopic lumbar discectomy in the treatment of lumbar disc herniation is the main objective. 100 patients with lumbar disc herniation who were treated in our hospital from February 2017 to February 2019 were selected as the control group (n=85, effective) and observation group (n=15, ineffective), the effective rate of treatment was statistically analyzed. Visual analogue scale and Japanese orthopaedic association scores were compared before surgery, 3 mo after surgery and 6 mo after surgery. The influencing factors of lumbar disc herniation treatment effect were analyzed. The effective rate of lumbar disc herniation patients treated by percutaneous transforaminal endoscopic lumbar discectomy surgery was 85.00 %. Compared with that before surgery, the visual analogue scale score of lumbar disc herniation patients was significantly decreased 3 mo after surgery and 6 mo after surgery, but the Japanese orthopaedic association score was significantly increased (p<0.05). In logistics regression analysis, it was found that the course of disease, history of trauma and degree of lumbago were the main factors affecting the therapeutic efficacy of percutaneous transforaminal endoscopic surgery in patients with lumbar disc herniation. There are many factors influencing the efficacy of percutaneous transforaminal endoscopic surgery for lumbar disc herniation patients and the relationship between them and the therapeutic effect should be comprehensively analyzed.
Percutaneous transforaminal endoscopic lumbar discectomy, lumbar disc herniation, shortterm efficacy, visual analogue scale score, Japanese orthopaedic association score
Lumbar disc herniation (LDH) is a common disease in spine surgery. It is the most common cause of lower back and lower leg pain and it mainly occurs in middle-aged and old people. The clinical manifestations of LDH include lumbago and sciatica, as well as pain, numbness and weakness of lower limbs. Treatment for LDH can be performed surgically and non-surgically, but after 3 mo of non-surgical treatment, the patient remains unresponsive and should be treated surgically. According to foreign studies, in the past, many surgical methods such as posterior discectomy and interbody fusion and internal fixation were used for the treatment of LDH. However, after clinical study, it was found that this surgery caused greater trauma to the patient and more damage to the patient's posterior column structure. In recent years, with the development of medical technology, percutaneous transforaminal endoscopic lumbar discectomy has achieved good results in the treatment of LDH and has the advantages of small trauma and ability to preserve the stability of patients lumbar posterior column structures. It has been widely used in clinical practice. Although there are many advantages of the percutaneous transforaminal endoscopic lumbar discectomy approach compared with the conventional approach, the clinical results show that some patients are still far less effective after surgery than expected. Therefore, the research focus is to explore the related factors that affect the efficacy of percutaneous transforaminal endoscopic lumbar discectomy in the treatment of LDH. This paper will explore the factors that affect the short-term efficacy of percutaneous transforaminal endoscopic lumbar discectomy in the treatment of LDH, in order to provide reference suggestions for clinical practice, which are reported as follows.
Materials and Methods
From February 2017 to February 2019, 100 LDH patients, 50 males and 50 females, aged 38-70 y, with a course of disease of 1-20 y, were selected and divided into observation group and control group according to the curative effect. All patients and their families were informed about the study and had signed the informed consent form.
Inclusion criteria and exclusion criteria:
Inclusion criteria-Complete clinical data; ineffective non-surgical treatment for more than 3 mo; successful percutaneous transforaminal endoscopic surgery; meeting diagnostic criteria for LDH; no previous surgical treatment. Exclusion criteria-Patients with severe autoimmune diseases; patients with intervertebral disc protrusion calcification; patients with lumbar spine instability or spondylolisthesis; patients with spinal tumor, infection or tuberculosis; patients with confusion who cannot cooperate with treatment.
The patient was placed in the prone position and the skin puncture point was first determined. Puncture points of L4~5, L5~S1 and L3~4 were located 12-14 cm and 8-10 cm next to the midline of the spinous process, respectively. The patient was given local anesthesia with 1 % lidocaine (Hebei Jiupai Pharmaceutical Co., Ltd., H20063371) after routine disinfection. Under the fluoroscopy of C-arm X-ray machine, insert the cervical intervertebral foramen into the intervertebral disc and inject 2 ml mixed solution of iodine contrast medium and methylene blue. The skin was then cut approximately 0.7 cm along the guide and placed through the guide wire into the dilating tube prior to placement in the working tube. Connect the endoscope system, observe the field of view of operation and clean the surrounding tissues. The position of nucleus pulposus was clearly highlighted and the stained blue denatured nucleus pulposus tissue was removed with a mini-nucleus pulposus forceps and the residual nucleus pulposus debris was carefully cleaned until the dural sac and nerve root was completely decompressed and the surgical field was repeatedly rinsed with sterile normal saline. The wound was closed after removal of the device. The procedure was completed.
Therapeutic response assessment:
Excellent-The patient's clinical symptoms are disappeared, with no effect on the patient's work and life. Good-The patient's symptoms are significantly improved or only mild limitation of activities. General- The patient's symptoms have improved, it has limited some of the patient's activities and has an impact on the patient's life and work. Poor-The patient's symptoms do not improve or is worsened and it has an impact on the patient's life and work. Of these, excellent and good are considered effective, while general and poor are considered ineffective.
Clinical efficacy-Evaluate the clinical efficacy of patients and group them according to their therapeutic efficacy. The patients who responded to treatment were used as the control group and the patients who failed to respond to treatment were used as the observation group. Visual analogue scale (VAS) and Japanese Orthopaedic Association (JOA) scores-Patients VAS and JOA were scored before surgery and 3 and 6 mo after surgery, respectively. Analysis of influencing factors-Taking the treatment effect of the patient as independent variable, single factor analysis was performed on the age, gender, course of disease, clinical manifestation, surgery segment, fibrous ring rupture or not, working mode and intervertebral disc degeneration grade of the patient and multi-factor logistics regression analysis was performed on the patients with significant difference in single factor analysis.
Statistical package for the social sciences (SPSS) 22.0 statistical software was used to analyze the data. Where, the measurement data conforming to normal distribution are expressed as mean±standard deviation (SD) (x̅±s) and t-test is used for inter-group comparison; case number (n) or percentage (%) is used for enumeration data and χ2 test is used for data comparison. Logistics regression analysis was used for multi-factor analysis and the difference was statistically significant when p<0.05.
Results and Discussion
Patient treatment effective rate was shown in Table 1. After percutaneous transforaminal endoscopic lumbar discectomy treatment, the effective rate of LDH patients was 85.00 %.
|Category||Number of cases (n=100)|
|Effective rate||85 (85.00)|
Table 1: Patient Treatment Effective Rate [n (%)]
VAS score and JOA score of patients before and after treatment was measured. Compared with that before operation, the VAS score of patients 3 mo and 6 mo after surgery were significantly lower, while the JOA score of patients in 3 mo and 6 mo after surgery were significantly higher than that before surgery and the differences had statistical significance (p<0.05); however, there was no significant difference between 6 mo after surgery and 3 mo after surgery and there was no statistical significance (p>0.05) (Table 2).
|Observation items||Before surgery||3 mo after surgery||6 mo after surgery|
Note: *indicates compared with that before surgery, p<0.05
Table 2: VAS Scores and JOA Scores of Patients Before and After Treatment
Single factor analysis affecting LDH was shown. The results of single factor χ2 test showed that the age, course of disease, Pfirrmann's classification of intervertebral disc and history of trauma of the patients in the observation group were higher than that in the control group and the degree of lumbago was significantly higher than that in the control group and the differences had statistical significance (p<0.05); while the gender, course of disease, working mode, pain manifestation, Modic change, surgery segment, fiber ring rupture and Lee partition of the patients in the observation group were not significantly different from those in the control group and there was no statistical significance (p>0.05) (Table 3).
|Dependent variable||Observation group (n=85)||Control group (n=15)||χ2 value||p value|
|Age||<45 y old||61||5||1.659||0.003|
|≥45 y old||24||10|
|Course of disease||<6 mo||40||1||1.264||0.002|
|Working mode||Free and easy type||45||8||0.264||0.264|
|Weight bearing type or sedentary type||40||7|
|Pain manifestation||Leg pain mainly||40||2||0.349||0.003|
|Lumbago and leg pain||5||10|
|Pfirrmann’s classification of intervertebral disc||Class II||5||1||1.0345||0.003|
|History of trauma||Yes||10||12||0.348||0.026|
|Fiber ring rupture||Yes||60||9||2.015||1.264|
|Lee partitioning||Zone 2||25||3||1.264||1.897|
Table 3: Single Factor Analysis of LDH (x̅±s, Case)
Multi-factor logistics regression analysis affecting LDH efficacy is shown here. Logistics regression analysis showed that course of disease, history of trauma and degree of lumbago were correlated with the curative effect of LDH patients (p<0.05), while age and Pfirrmann's classification of intervertebral disc were not correlated with the curative effect of patients (p>0.05) (Table 4).
|Index||Coefficient value (b)||Coefficient standard error (SE)||Odds ratio (OR)||OR 95 % confidence interval (CI)||Wald (χ2)||p|
|Course of disease||1.3756||0.4356||3.9758||1.7006~9.2885||10.1564||0.006|
|Pfirrmann’s classification of intervertebral disc||1.1135||0.7148||3.0495||0.7564~12.2658||2.4523||0.235|
|History of trauma||1.1126||0.2659||3.4512||1.4561~5.6482||6.2648||0.002|
|Degree of lumbago||1.1685||0.4002||3.2169||1.4662~7.0556||8.5026||0.005|
Table 4: Multi-Factor Logistics Regression Analysis Affecting LDH Efficacy
LDH is one of the most common degenerative diseases of spine and it is also the most common disease that causes lumbago and leg pain. For the treatment of LDH, in the past, the main clinical methods were push-plate fenestration and compression nucleus pulposus extraction, push-plate fenestration nucleus pulposus removal and so on. In recent years, with the development of science and technology and the widespread application of minimally invasive endoscopic techniques, percutaneous transforaminal endoscopic surgery has achieved good results in the treatment of LDH. According to the clinical study, the effective rate of treatment is about 80 %, which far exceeds that of previous treatment methods. After percutaneous transforaminal endoscopic lumbar discectomy treatment, the recovery time of patients is short due to their small trauma. After surgery, the adhesion of nerve root and dural sac is the result of the combination of local injury, hematoma formation and inflammatory reaction. The adhesion of nerve root may limit the movement of spinal cord and nerve root, generate the corresponding local change and finally cause the residual or recurrent phenomenon of patient's symptoms. While the transforaminal endoscopic surgical system (TESSYS) technique in the percutaneous transforaminal endoscopic lumbar discectomy addresses this problem, the TESSYS technique is based on refinement of a special spiral burr, grinding along the nerve root and removal of the ventral nucleus pulposus of the nerve root, hypertrophic calcified tissue, ligamentum flavum of the dorsal aspect, scar tissue, etc., to achieve complete never root release[9,10].
The percutaneous transforaminal endoscopic lumbar discectomy technique is becoming a state of the art technique and therefore has a higher requirement for those performing surgery, including having a good basis for open surgery, being familiar with local anatomy and being adept at hand-eye separation. Although the percutaneous transforaminal endoscopic lumbar discectomy technique has been shown to be effective in the treatment of LDH, it has been used clinically for relatively short periods of time and there are few relevant studies on the influencing factors of this technique in the treatment of patients with LDH. In the above study, the effective rate of percutaneous transforaminal endoscopic surgery in patients with LDH was 85.00 %. After percutaneous transforaminal endoscopic therapy, the pain scores of patients were significantly improved, indicating that the percutaneous transforaminal endoscopic therapy had less trauma to patients, which was consistent with the study by Huang et al.. The results of single factor analysis showed that the age, course of disease, Pfirrmann's classification of intervertebral disc, history of trauma and the degree of lumbago were closely related to the curative effect of LDH, but after the multi-factor logistics analysis, the course of disease, history of trauma and the degree of lumbago were correlated with the curative effect of LDH, while the age and Pfirrmann's classification of intervertebral disc were not correlated with the curative effect of LDH. This is similar to the results of Yilmaz et al..
It is analyzed that, for patients with a relatively long course of disease, the nerve damage of patients will be aggravated gradually, especially the long-term mechanical compression, immune reaction and inflammatory stimulation, which will make the nerve root in a high tension state. The long-term duration of this state will cause irreversible nerve injury, thus having an effect on the therapeutic efficacy of patients. The prominent symptoms of LDH mainly include leg pain, lumbago, as well as both lumbago and leg pain. Under normal conditions, leg pain is mainly associated with neuromechanical compression and lumbago is associated with neuroimmune response and inflammatory response. While the percutaneous transforaminal endoscopic lumbar discectomy technique alleviates neuromechanical compression, it has no significant effect in the treatment of neuroimmune and inflammatory responses and is therefore less effective in patients with low back pain. At the same time, for the patients with history of trauma, the intervertebral degeneration is obvious, most of them have local pathological changes such as lumbar spinal canal stenosis, intervertebral joint hyperplasia and nerve root adhesion, which will increase the difficulty of operation. In the above study, although the multi-factor regression analysis showed that age and Pfirrmann's classification of intervertebral disc were independent factors, it also had certain influence on the curative effect, among them, the age increased, the water content of nucleus pulposus, the elasticity of intervertebral disc and the anti-load ability decreased gradually, at the same time, the elderly patients had poor physical fitness and their organ function and osteoporosis were poor, which brought some difficulties to the surgery, while the Pfirrmann's classification of disc degeneration reflects the degree of disc degeneration, the greater the grade, the greater the degree of disc degeneration and the worse the effect of LDH. This is similar to the results of the study by Haijie et al..
In summary, factors affecting the short-term efficacy of LDH include the patient's course of disease, degree of lumbago and history of trauma. Care should be taken to stop bleeding during percutaneous transforaminal endoscopic lumbar discectomy surgery to avoid excessive bleeding that may affect the surgical field; attention should be paid to effective root release to avoid loss of tissues such as blood vessels, nerve roots and dura mater.
This work was supported by the Special Clinical Diagnosis and Treatment Technology Foundation of Suzhou (LCZX201513).
Conflicts of interest:
The authors declared no conflict of interest.
- Du W, Li H, Omisore OM, Wang L, Chen W, Sun X. Co-contraction characteristics of lumbar muscles in patients with lumbar disc herniation during different types of movement. Biomed Eng Online 2018;17(1):1-20.
- Son S, Lee SG, Kim WK, Ahn Y. Advantages of a microsurgical translaminar approach (keyhole laminotomy) for upper lumbar disc herniation. World Neurosurg 2018;119:e16-22.
- Dong Q, Ren G, Zhang K, Liu D, Dou Q, Hao D. Genetic polymorphisms of ALDH2 are associated with lumbar disc herniation in a Chinese Han population. Sci Rep 2018;8(1):1-7.
- Fei W, Chang-Xin L, Zhong-Gu T. Treatment of lumbar disc herniation with percutaneous intervertebral foramen combined with needle knife. Int J Clin Exp Med 2018,7(4):12-78.
- Xia DD, Yan MJ, Wu L, Hu B, Ge T, Wang XY, et al. Morphometric Analysis of Lumbar Intervertebral Foramen: A Radiographic Study. J Med Imaging Health Inform 2018;8(2):362-8.
- Dong Q, Ren G, Zhang K, Liu D, Dou Q, Hao D. Genetic polymorphisms of ALDH2 are associated with lumbar disc herniation in a Chinese Han population. Sci Rep 2018;8(1):1-7.
- Khalaf AM, Yedavalli V, Massoud TF. Magnetic resonance imaging anatomy and morphometry of lumbar intervertebral foramina to guide safe transforaminal subarachnoid punctures. Clin Anat 2020;33(3):405-13.
- Shin SH, Bae JS, Lee SH, Keum HJ, Jang WS. Transforaminal endoscopic discectomy for hard or calcified lumbar disc herniation: a new surgical technique and clinical outcomes. World Neurosurg 2020;143:e224-31.
- Lang Z, Li JS, Yang F, Yu Y, Khan K, Jenis LG, et al. Reoperation of decompression alone or decompression plus fusion surgeries for degenerative lumbar diseases: a systematic review. Eur Spine J 2019;28(6):1371-85.
- Nishikawa M, Inoue T. Thoracic ossification of the ligamentum flavum-neuroradiologic and pathologic findings based on our operative experience and a literature review. Spine 2018;5(3):23-30.
- Zheng-Tian G, Tian-Yang J, Cheng-Bing C. Analysis of the efficacy of intervertebral foramen in the treatment of degenerative lumbar spinal stenosis and analysis of postoperative recurrence factors. Int Med J 2019;8(5):56-60.
- Xin-Hua Z, Ye-Feng Z, Kai Z. Preliminary outcomes of percutaneous transforaminal endoscopic discectomy combined collagenase for treatment of contained lumbar disc herniation. Chin Med UK 2018;8(5):78-90.
- Huang BH, Zhong YM, Chen YM. Short-term outcome of complete spinal endoscopy via intervertebral foramen approach for lumbar spinal stenosis. Chin J Nat Med 2018;8(54):23-40.
- Yilmaz E, Cikrikcioglu HY, Baydur H. The effect of functional disability and quality of life on decision to have surgery in patients with lumbar disc herniation. Orthop Nurs 2018;37(4):246-52.
- Liang H, Guo W, Yang R, Tang X, Yan T, Ji T, et al. Radiological characteristics and predisposing factors of venous tumor thrombus in pelvic osteosarcoma: A mono‐institutional retrospective study of 115 cases. Cancer Med 2018;7(10):4903-13.