A prospective, randomized study comparing the results of open discectomy with those of video-assisted arthroscopic microdiscectomy. Outcome after lumbar sequestrectomy compared with microdiscectomy: a prospective randomized study. Report of a controlled clinical trial comparing automated percutaneous lumbar discectomy and microdiscectomy in the treatment of contained lumbar disc herniation. Anterior cervical microdiscectomy with or without fusion. A prospective randomized trial of chemonucleolysis and conventional disc surgery in single level lumbar disc herniation. Safety and efficacy of chymopapain (Discase) in the treatment of sciatica due to a herniated nucleus pulposus. Results of a randomized, double-blind study. Percutaneous endoscopic discectomy: surgical technique and preliminary results compared to microsurgical discectomy. Discectomy versus discectomy with fusion versus discectomy with fusion and instrumentation: a prospective randomized study. Surgery versus chemonucleolysis for herniated lumbar discs. A prospective study with random assignment.
The usefulness of video-assisted arthroscopic microdiscectomy for the treatment of a herniated lumbar disc has been studied previously. In the current prospective, randomized study, the results of this procedure were compared with those of conventional open laminotomy and discectomy.
                Sixty patients who had objective evidence of a single intracanalicular herniation of a lumbar disc caudad to the first lumbar vertebra were randomized into two groups consisting of thirty patients each; Group 1 was managed with open laminotomy and discectomy, and Group 2 was managed with video-assisted arthroscopic microdiscectomy. None of the patients had had a previous operation on the low back, and all had failed to respond to nonoperative measures. Analysis of the outcomes of both procedures was based on the patient's self-evaluation before and after the operation, the preoperative and postoperative clinical findings, and the patient's ability to return to a functional status. The patients were followed for nineteen to forty-two months postoperatively.
                On the basis of the patient's preoperative and postoperative self-evaluation, the findings on physical examination, and the patient's ability to return to work or to normal activity, twenty-eight patients (93 percent) in Group 1 and twenty-nine patients (97 percent) in Group 2 were considered to have had a satisfactory outcome. The mean duration of postoperative disability before the patients were able to return to work was considerably longer in Group 1 than in Group 2 (forty-nine compared with twenty-seven days). The patients in Group 1 used narcotics for a longer duration postoperatively. No neurovascular complications or infections were encountered in either group.
                Although the rate of satisfactory outcomes was approximately the same in both groups, the patients who had had an arthroscopic microdiscectomy had a shorter duration of postoperative disability and used narcotics for a shorter period. These findings suggest that arthroscopic microdiscectomy may be useful for the operative treatment of specific symptoms, including radiculopathy, that are caused by lumbar disc herniation, provided that patients are properly selected--that is, they must have a herniated disc at a single level as confirmed on imaging studies, have failed to respond to nonoperative management, have no evidence of spinal stenosis, and have a herniation not exceeding one-half of the anteroposterior diameter of the spinal canal. Moreover, the surgeon must be familiar with this technique and must have received training in its use. Microdiscectomy currently constitutes the standard treatment for herniated lumbar discs. Although limiting surgery to excision of fragments has occasionally been suggested, prospective data are lacking. Therefore, the objective of this study was to compare early outcome and recurrence rates after sequestrectomy and microdiscectomy.
                Eighty-four consecutive patients 60 years of age or younger who harbored free, subligamentary, or transanular herniated lumbar discs refractory to conservative treatment were randomized to one of two treatment groups. Intraoperative parameters and findings were documented as well as pre- and postoperative symptoms such as pain, Patient Satisfaction Index (PSI), Prolo Scale score, and Short Form (SF)-36 subscale results. Follow up of at least 12 months was available in 73 patients (87%). Preoperative intergroup symptoms did not differ significantly. Surgery was significantly shorter in the sequestrectomy-treated group. Overall, low-back pain and sciatica were drastically reduced in both groups and most sensorimotor deficits improved. At 4 to 6 months, SF-36 subscales and PSI scores showed a trend in favor of sequestrectomy, leaving 3% of patients unsatisfied compared with 18% of those treated with discectomy. Outcome according to the Prolo Scale was good or excellent in 76% of discectomy-treated patients and 92% of sequestrectomy-treated patients. Reherniation occurred in four patients after discectomy (10%) and two patients after sequestrectomy (5%) within 18 months.
                Sequestrectomy does not seem to entail a higher rate of early recurrences compared with microdiscectomy. Analysis of early outcome demonstrated a trend toward superior results when sequestrectomy is performed. Although long-term follow-up data are mandatory, sequestrectomy may be an advantageous alternative to standard microdiscectomy. The results of a randomized controlled trial comparing automated percutaneous lumbar discectomy (APLD) with lumbar microdiscectomy for the treatment of small contained lumbar discal herniations are reported. All patients gave full informed consent and were assessed by an independent observer. Seventy-one patients with radiologically confirmed small contained lumbar disc herniations were randomly assigned to undergo either APLD or lumbar microdiscectomy. All patients were formally assessed by the independent assessor using the Macnab outcome classification at 3 weeks, 2 months, and 6 months after the procedure with follow-up being continued for the duration of the study.
                The objective was to complete the first randomized and blinded study with sufficient numbers to provide a valid statistical evaluation of these procedures.
                No previous randomized controlled study comparing these methods has been previously reported.
                Each procedure was performed by the same surgeon using standard techniques. Statistical analysis was by the chi-square method.
                In the APLD group only 9 of 31 (29%) had satisfactory outcomes as compared to 32 of 40 (80%) for the microdiscectomy group. Of those patients in the APLD group who had an unsatisfactory outcome and who then opted to undergo surgery (20 of 22 patients), the final success rate was only 65%. Thus, the cumulative success rate of the group initially randomized to APLD including those undergoing either APLD alone or APLD and microdiscectomy after unsuccessful APLD was 22 of 31 (71%).
                In this group of patients, APLD is seen to be ineffective in the treatment of contained lumbar disc herniation. Anterior cervical microdiscectomy (ACD) is commonly applied in the surgical treatment of cervical disc herniation. However, following discectomy procedure to perform a fusion process is still controversial. Therefore, a controlled, multicentric, prospective, randomized study was designed.
                Totally 20 patients were operated. Eleven patients were operated with applying simple anterior microdiscectomy technique. Nine patients were operated via ACD and fusion with a semirigid plate technique. Preoperative and postoperative [immediate; postoperative first day and postoperative 1 y (mean 13.95 mo)] computed tomography studies and plain x-rays were obtained. The cervical disc and bilateral neural foramen heights of the operated level and adjacent segments were calculated. Pain assessment was performed using visual analog pain scale. Mann-Whitney statistical analysis method was applied to compare the outcomes for both groups.
                Satisfactory result was achieved in both groups. The pain scores for major complaint (arm pain) were decreased significantly in all patients after surgery regardless of the type of technique applied. The improvement in neck pain scores was significant only in patients who were treated with fusion procedure. There were no significant changes in disc height and neural foramen height measurements for both groups in adjacent levels in immediate and 1-year postoperative periods. The patients who were operated with simple ACD technique showed no significant decrease at postoperative first day in disc height and neural foramen height. However, the 1-year postoperative radiologic studies showed a significant decrease in disc height and neural foramen dimensions compared with preoperative values. The patients who were treated with fusion process showed a significant increase in disc height and nonsignificant increase in neural foramen heights at immediate postoperative study. However, with time, all dimensions showed significant decrease compared with preoperative values.
                ACD technique offers satisfactory outcome regardless of whether fusion process is applied or not. Fusion with semirigid plate offers an advantage at operated level in immediate postoperative period in regard of disc height and neural foramen height. However, semirigid anterior plates by definition do not stop subsidence and the advantage that is offered by this technique is not persistent. On the other hand, to apply fusion process with semirigid plate system offers significantly less narrowing in disc height compared with simple ACD technique. The role of chemonucleolysis as an alternative to disc surgery is still disputed. The authors conducted a prospective randomized controlled trial of chemonucleolysis and conventional disc surgery involving 92 patients with L4-5 or L5-S1 disc herniation who failed to respond to conservative treatment. There were 46 patients in each group, matched for demographic, clinical characteristics, and co-interventions. Independent examiners assessed patients before treatment, at 6 weeks after, 3 months after, and 1 year after treatment. A comprehensive method of outcome assessment involving physiological outcome, functional outcome, cost outcome, and psychological outcome was employed. Nine chemonucleolysis patients and one disc surgery patient required additional surgery for failure of initial treatment (P less than 0.02). The outcomes at 6 weeks and at 3 months were better in the surgical group, but at 1 year the differences were not significant. The authors conclude that chemonucleolysis as a minimally invasive technique produces inferior short-term results and offers no advantage over conventional discectomy. A prospective, multiinstitutional, double-blind trial comparing the effect of chymopapain (Discase) vs. placebo (cysteine-edetate-iothalamate: CEI) for lumbar intervertebral disc rupture with sciatica was carried out on 173 patients, the largest such study reported to date. Patients were matched with respect to age, sex, physical habitus, and level of injection. The procedure was carried out under local anaesthesia. The success rate was superior in the chymopapain group regardless of the method used to assess outcome or the time over the first 6 months at which the two groups were compared: 71% vs. 45% if code breaks were analyzed at 6 months, and 67% vs. 44% if code breaks were defined as lost to follow-up. A single case of anaphylaxis and one case of septic discitis were the only serious complications noted. This study supports the role of chymopapain in the treatment of lumbar disc rupture with sciatica. Percutaneous endoscopic discectomy is a new technique for removing "contained" lumbar disc herniations (those in which the outer border of the anulus fibrosus is intact) and small "noncontained" lumbar disc herniations (those at the level of the disc space and occupying less than one-third of the sagittal diameter of the spinal canal) through a posterolateral approach with the aid of specially developed instruments. The technique combines rigid straight, angled, and flexible forceps with automated high-power suction shaver and cutter systems. Access can thus be gained to the dorsal parts of the intervertebral space where the disc herniation is located. Percutaneous endoscopic discectomy is monitored using an endoscope angled to 70 degrees coupled with a television and video unit and is performed with the patient under local anesthesia and an anesthesiologist available if needed. Its indication is restricted to discogenic root compression with a minor neurological deficit. Two groups of patients with contained or small noncontained disc herniations were treated by either percutaneous endoscopic discectomy (20 cases) or microdiscectomy (20 cases). Both groups were investigated in a prospective randomized study in order to compare the efficacy of the two methods. The disc herniations were located at L2-3 (one patient), L3-4 (two patients), or L4-5 (37 patients). There were no significant differences between the two groups concerning age and sex distribution, preoperative evolution of complaints, prior conservative therapy, patient's occupation, preoperative disability, and clinical symptomatology. Two years after percutaneous endoscopic discectomy, sciatica had disappeared in 80% (16 of 20 patients), low-back pain in 47% (nine of 19 patients), sensory deficits in 92.3% (12 of 13 patients), and motor deficits in the one patient affected. Two years after microdiscectomy, sciatica had disappeared in 65% (13 of 20 patients), low-back pain in 25% (five of 20 patients), sensory deficits in 68.8% (11 of 16 patients), and motor deficits in all patients so affected. Only 72.2% of the patients in the microdiscectomy group had returned to their previous occupation versus 95% in the percutaneous endoscopic discectomy group. Percutaneous endoscopic discectomy appears to offer an alternative to microdiscectomy for patients with "contained" and small subligamentous lumbar disc herniations. The need for interbody fusion after anterior cervical discectomy for radiculopathy remains controversial. The purpose of this study was to assess clinical and radiographic outcomes in patients with cervical radiculopathy after discectomy without fusion (ACD), discectomy with intervertebral fusion (ACDF), and discectomy with intervertebral fusion and instrumentation (ACDFI).
                Forty-two consecutive patients with cervical radiculopathy who failed medical management were randomized to one of three treatment groups: ACD, ACDF, or ACDFI. Indices including symptoms, work status, Short Form-36, McGill pain scores, and anteroposterior/lateral flexion/extension x-rays were obtained preoperatively and during the follow-up period.
                There were no inter-group differences observed during the 2-year follow-up period with respect to neck pain, interscapular pain, or arm pain (P > 0.05). Short Form-36 scores demonstrated a dramatic postoperative improvement followed by further gradual improvement in both physical and mental components as well as other subscale scores in all groups during the follow-up period (P < 0.05). Fusion occurred in 67% of the ACD patients compared with 93% of the ACDF patients and 100% of the ACDFI patients (P < 0.05). Segmental kyphosis was noted in 75% of the ACD patients postoperatively compared with 17% preoperatively. There was no change in sagittal balance in the ACDF or ACDFI groups (P > 0.05).
                Patient selection and surgical decompression remain the key to achieving desirable clinical outcomes after cervical discectomy for radiculopathy. Within a 2-year follow-up period, the technique of reconstruction plays no role in clinical results. However, ACD alone results in segmental kyphosis compared with ACDF and ACDFI. The results of removal of a disc hernia at the L4/L5 level were compared with those obtained by the injection of 4000 IU (2 ml) of chymopapain (Discase) in 29 consecutive patients randomly selected for either treatment. All exhibited severe incapacitating sciatica, and all had a myelogram demonstrating a definite disc hernia. The two groups of patients did not differ significantly with regard to age, sex, or length of history. The total time of general anesthesia was significantly shorter for the injected patients by 20 minutes (p less than 0.01), as was the length of hospitalization, by three days (p less than 0.05). Within five months, eight of the patients receiving chymopapain injections had to be operated on because of unrelieved symptoms. All had definite disc herniae, and in four, a free fragment was found. All patients were seen at the time of dismissal from the hospital and at six and 12 months after operation by an independent observer. Comparisons made at these intervals, following either surgery or chymopapain injection with or without subsequent surgery, did not reveal any significant differences, but the short-term results following either treatment alone significantly (p less than 0.01) favored the surgical approach.
Surgical discectomy for carefully selected patients with sciatica due to lumbar disc prolapse provides faster relief from the acute attack than conservative management, although any positive or negative effects on the lifetime natural history of the underlying disc disease are still unclear. Microdiscectomy gives broadly comparable results to open discectomy. The evidence on other minimally invasive techniques remains unclear (with the exception of chemonucleolysis using chymopapain, which is no longer widely available).