1. Percutaneous transforaminal endoscopic discectomy (PTED) was non-inferior to open microdiscectomy in reduction of leg pain
Evidence Rating Level: 1 (Excellent)
Study Rundown: Sciatica is a common health problem. Most frequently caused by lumbar disc herniation, sciatica is typically characterized by radiating leg pain starting from the low back, sometimes accompanied by sensory or motor deficits. In most people, sciatica has a favourable natural course. However, when conservative treatment fails or progressive neurological deficits develop, surgery may be indicated. The standard procedure for treating lumbar disc herniation is open microdiscectomy. However, other surgical techniques that are less invasive in nature have also been developed. One of these techniques is percutaneous transforaminal endoscopic discectomy (PTED). PTED is expected to lead to shorter hospital admission, faster recovery time and less postoperative back pain because general anesthesia is not used, paraspinal muscles are not detached from their insertion points, and bony anatomy is not changed. This randomized controlled trial aimed to assess whether PTED is non-inferior to conventional open microdiscectomy in reduction of leg pain caused by lumbar disc herniation. Participants included a total of 613 patients aged 18-70 with at least six weeks of radiating leg pain caused by lumbar disc herniation. Patients were randomized in a one to one ratio to PTED or open microdiscectomy. The primary outcome measure was self-reported leg pain measured by a 0-100 visual analogue scale at 12 months. At 12 months, patients who were randomized to PTED had a statistically significantly lower visual analogue scale score for leg pain (median 7.0, interquartile range 1.0-30.0) compared with patients randomized to open microdiscectomy (16.0, 2.0-53.5) (between group difference of 7.1, 95% confidence interval 2.8 to 11.3). It was concluded that PTED was non-inferior to open microdiscectomy in reduction of leg pain.
Click here to read the study in The BMJ
Relevant Reading: Surgery versus conservative care for persistent sciatica lasting 4 to 12 months
In-Depth [Randomized Controlled Trial]: This study was conducted at four general hospitals in the Netherlands in patients with sciatica caused by lumbar disc herniation. Patients were eligible if they had an indication for surgery, meaning at least six weeks of excessive radiating leg pain with no evidence of clinical improvement on conservative therapy. Other inclusion criteria were age between 18 and 70 years, confirmation of a nerve root compression by a lumbar disc herniation on magnetic resonance imaging, and sufficient knowledge of the Dutch language to complete forms and follow instructions. Exclusion criteria were previous surgery at the same or adjacent disc level, cauda equina syndrome, isthmic or degenerative spondylolisthesis, pregnancy, severe comorbid medical or psychiatric disorder, severe caudal or cranial sequestration of disc fragments, contraindication for surgery, and moving abroad on short notice. Participants were randomly assigned to receive either PTED or open microdiscectomy. The primary outcome was the improvement in leg pain at one year, as measured with a visual analogue scale ranging from 0 to 100 with higher scores indicating more leg pain. Secondary outcomes were functional status as measured with the Oswestry Disability Index, back pain, quality of life, physical and mental health as measured with the short form 36 (SF-36), and self-perceived recovery from symptoms, recovery from leg pain, satisfaction with treatment, and change in symptoms. Between February 2016 and April 2019, 613 patients were enrolled in the study. Of the 304 patients randomized to PTED, 286 (94%) received the intervention. Of the 309 patients randomized to open microdiscectomy, 244 (79%) underwent surgery. At 12 months follow-up, the primary outcome was available for 532 (87%) of the randomized patients. The median visual analogue scale for leg pain showed a similar improvement in leg pain in both groups following surgery. In the first three months, mean differences in reduction of leg pain between the groups were small. At six, nine, and 12 months, mean differences in favour of PTED increased. At 12 months’ follow-up, the mean between group difference in leg pain was 7.1 (95% confidence interval 2.8 to 11.3) in favour of PTED. In general, mean differences in secondary outcomes between both groups were small in the first three months and increased in favour of PTED at six, nine, and 12 months. These results suggest that PTED can be considered as an effective alternative to open microdiscectomy in treating sciatica.
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