Clinical efficacy of percutaneous endoscopic posterior lumbar interbody fusion and modified posterior lumbar interbody fusion in the treatment of lumbar degenerative disease

doi:10.21203/rs.3.rs-3313507/v1

Background: To compare the early clinical efficacy of percutaneous endoscopic posterior lumbar interbody fusion (PE-PLIF) and modified posterior lumbar interbody fusion (MPLIF) in the treatment of lumbar degenerative disease (LDD).

Methods: Retrospective cohort study. Ninety-five patients who were hospitalized in our department for surgical treatment of single-segment LDD from March 2019 to January 2022. They were divided into a PE-PLIF group (37 cases) and an MPLIF group (58 cases) according to the type of surgery. The operation time, intraoperative blood loss, postoperative hospitalization time, and postoperative bedridden time were recorded. The visual analogue scale (VAS) scores of leg pain and low back pain, Japanese orthopaedic association (JOA) scores, and Oswestry disability index (ODI) scores were assessed and compared before operation, 3 days after operation, 1 week after operation, 1 month after operation, 6 months after operation and the last follow-up. The modified MacNab’s criteria were recorded at the last follow-up. The fusion rate and surgical-related complications during follow-up were recorded.

Results: There were no statistical difference in preoperative baseline between the two groups. The average operation time in the PE-PLIF group was highly significant longer than that in the MPLIF group (P < 0.01). Intraoperative blood loss, postoperative hospitalization time, and postoperative bedridden time were highly significant less in the PE-PLIF group than those in the MPLIF group (P < 0.01). There were highly significant differences in VAS scores of leg pain, VAS scores of low back pain, JOA scores, ODI scores at the last follow-up compared with those before surgery in the two groups (P < 0.01). At the same follow-up point, there was no statistical difference in the VAS scores of leg pain between the two groups(P＞0.05). 3 days after operation and 1 week after operation, the VAS scores of low back pain and ODI were highly significant less in the PE-PLIF group than that in the MPLIF group (P < 0.01). 3 days after operation, the JOA scores were highly significant higher in the PE-PLIF group than that in the MPLIF group (P < 0.01). At the last follow-up, the excellent rate of modified MacNab was 97.3% in the PE-PLIF group and 98.3% in the MPLIF group, which was no statistical difference (P > 0.05). All patients were obtained fusion at 6 months after operation. Two patients (5.4%) in the PE-PLIF group had complications.

Conclusion: Both PE-PLIF and MPLIF surgery have a satisfactory clinical efficacy and safety for patients with LDD. Compared with MPLIF, PE-PLIF has the advantages of less intraoperative blood, faster recovery time, and less tissue damage. PE-PLIF surgery can be used as an alternative treatment for single-segment LDD.

percutaneous endoscopic posterior lumbar interbody fusion

modified posterior lumbar interbody fusion

lumbar degenerative disease

clinical outcome

Lumbar degenerative disease (LDD) is a general term for a series of diseases with clinical symptoms such as low back pain and leg pain, and it is caused by degenerative changes of lumbar intervertebral disc, articular process and ligaments. Lumbar discectomy and lumbar interbody fusion (LIF) are the main treatment methods for LDD when conservative treatment is ineffective(1). LIF is an important method to achieve complete decompression and rebuild spinal function. The main indications of LIF include lumbar spinal stenosis (LSS), lumbar spondylolisthesis (LS), lumbar disc herniation, and scoliosis. LIF is widely used in clinic because it can alleviate pain, relieve nerve root compression, redress lordosis and correct spinal deformity. Posterior lumbar interbody fusion (PLIF) is a well-established technique with a definite efficacy for treating LDD. Traditional PLIF, however, necessitates extensive removal of the vertebral lamina, spinous process, supraspinous ligament, interspinous ligament, ligamentum flavum, and facet joints, which damages the posterior spinal ligament complex, compromises the stability of spine, and raises the risk of adjacent segment degeneration (ASD)(2). The preservation of the posterior spinal ligament complex can maintain the stability and flexibility of the spine, hold the physiological and mechanical function of the spine, and prevent the occurrence of ASD after PLIF (2, 3). Modified posterior interbody fusion (MPLIF) reduces the destruction of normal spinal structure, retains spinous process and posterior spinal ligament complex, with good clinical efficacies ⁽³⁾. Therefore, we use MPLIF to treat patients with LDD. With the development of minimally invasive techniques, more and more surgeons have used percutaneous endoscopic lumbar interbody fusion (PE-LIF) to treat patients with LDD. PE-LIF has advantages in little muscle injuries and fast recoveries, and it is a promising treatment for LDD(4–6). Percutaneous endoscopic posterior lumbar interbody fusion (PE-PLIF) is a common treatment method in clinical for LDD. Currently, there are few studies comparing the clinical efficacy of PE-PLIF with MPLIF in the treatment of LDD. In this study, we analyze perioperative parameters, clinical and radiological outcomes of PE-PLIF and MPLIF, in order to evaluate the early clinical efficacy of PE-PLIF and MPLIF in the treatment of LDD.

General data

Retrospective cohort study. This study collected clinical data from patients who underwent PE-PLIF surgery and MPLIF surgery for LDD in our hospital during March 2019 to January 2022. The PE-PLIF surgery was used for the PE-PLIF group (37 cases), and the MPLIF surgery was used for the MPLIF group (58 cases). There were no significant differences in gender, age, disease type, surgical segment and follow-up time between the two groups (P > 0.05, Table 1). All patients signed informed consent forms. All procedures were performed by the same group of senior spine surgeons with extensive experience in endoscopic and open surgery. The study was approved by the hospital ethics committee.

Inclusion criteria:

(1) Patients diagnosed with single-segment LDD, including LS (Meyerding ≤Ⅱ), LSS, with or without disc herniation, whose symptoms and signs were consistent with lumbar X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) (Figure 1);

(2) Patients with persistent neurological symptoms or typical intermittent claudication symptoms;

(3) Symptoms could not be alleviated or were aggravated after at least 3 months of nonsurgical treatment;

(4) Patients with PE-PLIF or MPLIF surgery.

Exclusion criteria:

(1) Patients with obvious scoliosis or kyphosis;

(2) Patients with severe heart, brain, kidney or other types of disease who could not tolerate the surgery;

(3)A history of lumbar surgery;

(4) Severe osteoporosis;

(5) Lumbar tumor, tuberculosis or infection;

(6) Patients and families who did not consent to the study;

(7) Patients with psychological disorders or mental disorders.

Surgical methods

1.PE-PLIF

All operations were completed under general anesthesia. Patients were in the prone position. The table was adjusted to moderately flex the lumbar and expand the intervertebral space appropriately. Surgical level was confirmed under C-arm fluoroscopy prior to operation. Completing routine disinfection and towel laying. The skin incision was located next to the targeted intervertebral space, approximately 2 cm away from the spinous process. A longitudinal incision of approximately 15 mm was made. The incision was gradually expanded with soft tissue dilatation tubes to insert the working channel. A large channel spinal endoscopy system (Unintech system, Joimax, Germany) was used in the surgery. In the surgery section, the anatomical structures such as the upper and lower vertebral laminas, the articular process and the ligamentum flavum were revealed sequentially under the endoscope with a straight forceps, curved forceps and a radiofrequency ablation electrode (APS-A-01-N-7030 /Aceso -Suzhou). The bony structures such as the superior vertebral body portion of the vertebral lamina, the inferior articular process (IAP), the lateral recess, and the inferior vertebral body portion of the vertebral lamina in the operative area were sequential removed by using a visual trephine with an endoscopic bone knife until the origin and end of the ligamentum flavum was revealed. The lateral wall of the superior articular process (SAP) was preserved to protect the exiting nerve roots. The ligamentum flavum was partially excised to expose the nerve roots, dural sacs, and intervertebral disc. The working channel was rotated so that its bevel moved toward the lateral side to prevent nerve roots from entering the working space. Nucleus forceps were used to extract nucleus pulposus, and reamers and scrapers were used to trim the cartilaginous endplate. After the endplates were completely prepared, autologous bone, allograft bone (Aoli, Shanxi, OSTEORAD Biomaterial Co., Ltd. Taiyuan), recombinant human bone morphogenetic protein-2 (rhBMP-2) (Hangzhou Jiuyuan, rhBMP-2, Hangzhou Jiuyuan Gene Engineering Co., Ltd.) and an expandable cage (Shanghai Reach Medical Instrument Co., Ltd) were implanted into the intervertebral space. After the decompression of spinal canal and the position of cage was checked satisfactorily under fluoroscopy and endoscopy, the endoscope and the working channel were withdrawn. Finally, percutaneous pedicle screws (RS8 LONG Long Tail Minimally Invasive System, Shanghai Reach Medical Instrument Co., Ltd) and connecting rods were implanted, the skin incision was sutured, and a drainage tube was usually not placed. A drainage tube was placed in case of excessive bleeding (After decompression, the normal saline perfusion was turned off, and all the blood oozed under the endoscope). The drainage tube could be removed 1–2 days after the operation depending on the amount of drainage(7). The incision was bandaged to end the operation. (Figure 2)

2. MPLIF

All operations were completed under general anesthesia. Patients were in the prone position. The table was adjusted to moderately fix the lumbar. Completing routine disinfection and towel laying. A longitudinal incision was made along the midline of the spinous process at the surgery section. The spinous process and the posterior spinal ligament complex were preserved. The bilateral paraspinal muscles were dissociated from the subperiosteum and exposed to the lateral margin of the articular process. Pedicle screws were inserted into the superior outer edge of the apex of the “∧” shape crest. After position of the pedicle screws was satisfactory, decompression was performed on the affected side (unilateral or bilateral). The parts of the upper and lower vertebral laminas, approximately 1/3 of the IAP, SAP, and ligamentum flavum were removed. The dural sacs and nerve roots were protected, and the intervertebral space was treated until the cartilaginous endplate bleeding was punctate. After the endplates were completely prepared, the bone grafts and a suitable cage were inserted in the intervertebral space. Bilateral connecting rods were installed and fixed with appropriate pressure. The wound was sutured after complete hemostasis and catheter drainage.

Postoperative treatment

After surgery, patients in both groups were routinely bedridden and received the same rehydration regimen, including painkillers. Patients were in bed for 1-2 days in the PE-PILF group and 4-5 days the MPLIF group. According on Caprini’s scores, appropriate regimens of thrombosis prevention were chosen for patients(8). All patients were encouraged to turn over in bed and lift their legs while receiving leg pressure therapy to prevent thrombosis. Patients without the placement of a drainage tube were reexamined lumbar x-ray and CT on the first day after surgery, while patients with the placement of a drainage tube were reexamined lumbar x-ray and CT on the day which drainage tubes were removed (Figure 3). If the internal fixation and cage position were satisfactory, the patients got out of bed with the assistance of lumbar brace.

Observation index

1. Surgical-related index

The surgical-related outcomes of the two groups were recorded, mainly including the operation time, intraoperative blood loss, postoperative hospitalization time, postoperative bedridden time, and complications.

2. Clinical efficacy index

All patients were evaluated with visual analogue scale (VAS) scores, Japanese orthopaedic association (JOA) scores and Oswestry disability index (ODI) during preoperation (1 day prior to operation), as well as 3 days, 1 week, 1 month, 6 months after operation and the last follow-up. The last follow-up recorded modified MacNab’s criteria.

The VAS scores were adopted to assess the low back pain and leg pain, ranging from 0 to 10 points. The higher score indicated the more severe pain(9).

The JOA scores were adopted to assess the neurological function, ranging from 0 to 29 points. The higher score indicated the more significant improvement of neurological function(9).

The ODI was adopted to assess the physical dysfunction with a total of 50 points. The higher score indicated the more serious the physical dysfunction and the worse the quality of life(10).

The modified MacNab’s criteria were adopted to assess the treatment outcomes of the patients(9). The criteria were as follows with four grades. Excellent: symptoms disappeared completely, returning to the original work and life. Good: slight symptoms, slightly limited activities, no effect on work and life. Fair: symptoms were relieved, but activities were limited, affecting normal work and life. Poor: there was no difference in the perioperative period, even aggravated.

3. Radiological evaluation index

Lumbar anteroposterior, lateral and dynamic x-ray radiographs were collected before operation. Lumbar anteroposterior and lateral x-ray radiographs were collected at 1 month, 3 months and 6 months postoperatively. The final fusion grade was assessed 6 months after surgery using the Bridwell criteria on CT images(11). Grade Ⅰ, fused with remodeling and trabeculae present; Grade Ⅱ, graft intact, not fully remodeled and incorporated, but no lucency present; Grade Ⅲ, graft intact, potential lucency present at the top and bottom of the graft; Grade Ⅳ, fusion absent with collapse/resorption of the graft.

Statistical analysis

All statistical analyses were performed using the SPSS 27.0. General data were described statistically, and data that did not conform to the normal distribution were represented by the median (first quartile, third quartile). Mann-Whitney U test was used to compare the differences between the two groups, and Friedman test was used to compare the groups at different time points and multiple comparisons. Categorical variables were expressed as frequency or percentage and were compared with the chi-squared test or Fisher's exact test. P < 0.05 was considered statistically significant, and P < 0.01 was deemed highly significant.

Surgery-related index

In the PE-PLIF group, the average operation time was significantly longer than the MPLIF group (P < 0.01). The intraoperative blood loss in the PE-PLIF group was significantly less than the MPLIF group (P < 0.01). Moreover, the postoperative bedridden time was considerably shorter than the MPLIF group (P < 0.01). Additionally, the postoperative hospitalization time was significantly shorter than the PE-PLIF group (P < 0.01) (Table 2).

Clinical efficacy index

There were no statistically significant differences in preoperative VAS scores of leg pain and low back pain, JOA scores and ODI scores between PE-PLIF group and MPLIF group (P > 0.05) (Table 3).

The VAS scores of leg pain at any follow-up point was highly significant lower in the two groups than before operation (P < 0.01). Compared with 1 week after operation and 3 days after operation, the VAS scores of leg pain were highly significant different (P < 0.01). There was no statistical difference in VAS scores of leg pain between 1 month after operation and 1 week after operation, 6 months after operation and 1 month after operation, and the last follow-up and 6 months after operation (P > 0.05). There was no statistical difference in the same follow-up points between the two groups (P > 0.05) (Table 3).

In the PE-PLIF group: The VAS scores of low back pain and ODI at 3 days after operation were lower than those before the operation (P < 0.05), and the other follow up points were highly significant lower than those before the operation (P < 0.01), and any follow-up points of JOA were highly significant higher than those before operation (P < 0.01). There were no significant differences in VAS scores of low back pain, JOA and ODI between 1 week after operation and 3 days after operation, 1 month after operation and 1 week after operation, and the last follow-up and 6 months after operation (P > 0.05) (Table 3).

In the MPLIF group: 3 days after operation, the VAS scores of low back pain and ODI were no statistical differences between those before the operation (P > 0.05), and JOA were higher than those before operation (P < 0.05). 1 week after operation, the VAS scores of low back pain were lower than those before the operation (P < 0.05). The VAS scores of low back pain, JOA and ODI at the other follow up points were highly significant differences than those before the operation (P < 0.01). There were statistical differences in the VAS of low back pain 1 week after surgery compared with 3 days after operation (P < 0.05), and highly significant differences in JOA and ODI (P < 0.01). There were highly significant differences in the VAS scores of low back pain and ODI 1 month after operation compared with 1 week after operation (P < 0.01), while JOA showed no statistical difference (P > 0.05). There were no significant differences in the VAS scores of low back pain, JOA and ODI between 6 months after operation and 1 month after operation, and between the last follow-up and 6 months after operation (P > 0.05).

Compared with the two groups, the VAS scores of low back pain, JOA and ODI of the PE-PLIF group were highly significant differences than those of the MPLIF group at 3 days after operation (P < 0.01), and the VAS and ODI of the PE-PLIF group were highly significant lower than those of the MPLIF group at 1 week after operation (P < 0.01), with no statistical difference at other same follow up points (P >0.05) (Table 3).

At the last follow-up, the excellent rate of modified MacNab was 97.3% in the PE-PLIF group and 98.3% in the PLIF group (P > 0.05), with no significant difference (Table 2). In the PE-PLIF and MPLIF groups, all patients achieved good results.

Imaging results

The Bridwell’s criteria were adopted to assess the intervertebral fusion at 6 months after operation. At 6 months after operation, patients in both the PE-PLIF and MPLIF groups achieved intervertebral fusion.

Complication

In this study, major complications such as dural tear, cerebrospinal fluid leakage and infection did not occur in the two groups. Two patients (5.4%) in the PE-PLIF group experienced surgical complications. The symptoms secondary to contralateral nerve root compression was found in one patient. The symptoms completely released after ozone ablation. One patient experienced more severe pain and numbness in the right lower limb than before surgery after the PE-PLIF procedure. The symptoms were alleviated after percutaneous endoscopic discectomy. No surgical complications occurred in the MPLIF group (Table 2).

Leu et al.(12) reported PE-LIF technology for the first time in 1996, but it did not develop rapidly. Subsequently, Jacquot et al.(13) used PE-LIF, but reported a high postoperative complication rate up to 36% and did not recommend it unless significant technical improvements were made. In recent years, with the development of spinal endoscopic devices, instruments and techniques, this technique has regained the attention of minimally invasive spinal surgeons. Both transforaminal and posterior approaches are frequently used in PE-LIF. Percutaneous endoscopic transforaminal lumbar interbody has some shortcomings such as limited decompression range and easy damage of exiting roots because the limited space of kambin triangle(14, 15). In posterior approach, the operational field is quite similar to that of open PLIF and the working channel enters into the spinal canal through partial facetectomy and laminoplasty. The residual articular process can minimize the possibility of exiting nerve injury(16). PE-PLIF has the advantages of wide range of decompression and small stimulation of exiting nerve.

In this study, the results showed that PE-PLIF had significant advantages over MPLIF in terms of intraoperative blood loss, postoperative hospitalization time and postoperative bedridden time, but the operation time of PE-PLIF was significantly longer than that of MPLIF. In the early postoperative stage of PE-PLIF, the low back pain, leg pain and quality of life were significantly improved. Our results were similar to the results of previous studies(16, 17) .

According to the study's findings, the PE-PLIF group experienced less intraoperative blood loss than the MPLIF group, which may be attributed to the following factors. First, bleeding can be prevented in advance by using radiofrequency ablation under the endoscopic field of vision, which can provide a clear surgical field of vision and reduce intraoperative bleeding(4). Second, continuous fluid irrigation plays a vital role in controlling epidural and bone surface bleeding, which can reduce intraoperative blood loss(18). Third, the adjacent pedicles will not be injured because visible trephine is used for facetectomy(19), with a small scope of bone resection and less bone bleeding, which is conducive to reducing intraoperative blood loss.

The operation time of PE-PLIF was significantly longer than that of MPLIF. PE-PLIF spent more time on spinal decompression and endplate preparation since smaller tools were used for facetectomy and discectomy(17, 20). Fluoroscopy was required for the location of the skin incision to the determination of the channel, the satisfactory position of the cage in the intervertebral space, and the placement of the percutaneous pedicle screws, which potentially led to a prolonged operating time due to the number of fluoroscopies. The learning curve of PE-PLIF is steep(1). As the number of operations increases, the operation time in the later stages of PE-PLIF steadily decreases while its relatively long in the early stages. Fluoroscopy time and operation time can be decreased when more surgeries are performed by surgeons(21). We have also made some process improvements to shorten the operation time of PE-PLIF, and the exact effect of these improvements needs to be observed in the control of large samples.

After spinal surgery, the effect of decompression is associated with the degree of recovery from leg pain(22). Our study's findings demonstrated that postoperative leg’s pain was greatly reduced in both groups and almost eliminated within the 1 week after operation. It demonstrates that PE-PLIF and MPLIF both have the same decompression effect.

Our results showed that postoperative low back pain was significantly improved in both groups. In the PE-PLIF group, the low back pain vanished 3 days after operation, but there was no appreciable improvement in the MPLIF group at this time. In the MPLIF group, the low back pain gradually subsided 1 week after operation and vanished completely 1 month later. The PE-PLIF group had a shorter recovery period following surgery for low back pain, which was a benefit since there was less paravertebral muscle and soft tissue damage. The PE-PLIF group had a shorter recovery period after operation for low back pain, which was a benefit since there was less paravertebral muscle and soft tissue damage. Liu et al. (5) had reported that the endoscopic spinal fusion surgery group had lower serum C-reactive protein, erythrocyte sedimentation rate, and creatine kinase levels than the conventional PLIF group. It demonstrated that there was less localized injury and less inflammation in the endoscopic spinal fusion surgery group. In the PE-PLIF group, several patients experienced severe postoperative low back pain during the early surgery. Postoperative low back pain may be associated with myofascial pain syndrome (MPS). MPS is characterized by the presence of trigger points in taut area of skeletal muscle and fascia(23, 24). When the trigger points are activated, the localized pain will appear. The symptom can be relieved by local drug treatment(24). Patients, who underwent the early PE-PLIF surgery, experienced postoperative low back pain with tender points. The tender points were below the connecting rods. Postoperative low back pain, in the operative area, may be accompanied by activation of myofascial trigger points. In the early cases, the fascial incision was insufficient which led to the skeletal muscle and fascia were highly in taut. The connecting rods stimulated trigger points in the taut area of the muscle and fascia, resulting in severely postoperative low back pain. The symptom was relieved after local drug therapy. In later cases, we fully incised the fascia to reduce the degree of tautness between muscle and fascia. The occurrence of the symptom was significantly decreased.

In both groups, neurological function and the degree of limb dysfunction were dramatically improved. 3 days after operation, the degree of nerve function and limb dysfunction in the PE-PLIF group essentially reverted to normal, which may be connected to the disappearance of low back pain in the early postoperative period. The minimally invasive nature of PE-PLIF can enhance patient quality of life in the early postoperative period and encourage postoperative rehabilitation of patients, allowing patients to return to their regular social lives sooner, which is consistent with the idea of enhanced recovery after surgery (ERAS). In this study, modified MacNab’s criteria were assessed at the last follow-up, and the excellent and good rate was 97.3% in the PE-PLIF group and 98.3% in the MPLIF group. Both PE-PLIF and MPLIF showed good treatment outcomes.

It is critical for patients who experienced LIF to evaluate fusion rate. Failed intervertebral fusion causes the cage to migrate slightly, thereby increasing the risk of endplate injury and cage subsidence/migration(25), which may affect surgical outcomes and quality of life. A study showed that, at 12 months after surgery, the CT fusion rate of PE-LIF was 85.3%(26). Insufficient intervertebral bone graft may lead to delayed intervertebral fusion(25). In this study, all patients got fusion at 6 months after surgery. Because the volume of autogenous bone in PE-PLIF was low, we implanted a mixture of autogenous bone and allograft bone with an appropriate size cage into the intervertebral space. In PE-PLIF, endplate was prepared under endoscopic view. It could completely remove the endplate cartilage and reduce endplate damage by the magnification of the endoscope, which could provide a favorable fusion environment. The combination of PE-LIF and percutaneous pedicle screws has been widely used and studied in LDD (9, 21). Percutaneous pedicle screws help achieve stability similar to that of open devices, which can keep stability at the target level. Intervertebral fusion may benefit from appropriate interbody grafts, a favorable fusion environment, and the stable spine.

However, PE-PLIF technique also has some limitations. The surgical indications in PE-PLIF are limited, which cannot be used in patients with severe lumbar spondylolisthesis and the demand of extreme lateral decompression(16). With the development of surgical techniques and instruments, the indications may be further extended. Fluoroscopy is required for the location of the skin incision to the determination of the channel, the satisfactory position of the cage in the intervertebral space, and the placement of the percutaneous pedicle screws, which lead to large radiation exposure doses for the patient and operators. In PE-PLIF, the learning curve is steep in the initial stage, the scope of visual field under the endoscope is limited, and the operation under the endoscopic is difficult(1, 21). It is difficult for beginners to adapt to both endoscopic lumbar surgery and percutaneous pedicle screw implantation. The surgeons should perform simple endoscopic decompression in the early stage, and then gradually carry out PE-PLIF after some experience in endoscopic technology. To increase safety and efficiency, more advanced trainings for surgeons in endoscopic surgery are advocated. The development of endoscopic instruments and the accumulation of endoscopic decompression experience are conducive to the improvement of the learning curve of PE-PLIF technique. PE-PLIF, combined with navigation system and robot-assisted technology, can greatly eliminate the complexity and learning curve of endoscopic technology, improve the safety and accuracy of surgery, shorten the operation time, and reduce radiation exposure(27–31).

Limitation

Limitations of this study include: (1) This study is a retrospective, non-randomized controlled study, which may have partial selection bias; (2) The sample size of this study is small, and more studies in large sample size are required to increase the reliability of the findings; (3) The follow-up time of this study is short, and a longer follow-up time is needed to evaluate the long-term efficacy and complications.

In our study, PE-PLIF and MPLIF have good early clinical efficacy and safety in the treatment of single-segment LDD patients. PE-PLIF is a promising technique that can be used as an alternative treatment for single-segment LDD.

LDD

Lumbar degenerative disease

LIF

Lumbar discectomy and lumbar interbody fusion

LSS

Lumbar spinal stenosis

LS

Lumbar spondylolisthesis

PLIF

Posterior lumbar interbody fusion

ASD

Adjacent segment degeneration

MPLIF

Modified posterior lumbar interbody fusion

PE-LIF

Percutaneous endoscopic lumbar interbody fusion

PE-PLIF

Percutaneous endoscopic posterior lumbar interbody fusion

CT

Computed tomography

MRI

Magnetic resonance imaging

IAP

Inferior articular process

SAP

Superior articular process

rhBMP-2

recombinant human bone morphogenetic protein-2

VAS

Visual analogue scale

JOA

Japanese orthopaedic association

ODI

Oswestry disability index

MPS

Myofascial pain syndrome

ERAS

Enhanced recovery after surgery

The Affiliated Hospital of Wuhan Sports University Ethics Committee approved this retrospective observational study.

The committee’s reference number was HB67221136.

Consent for publication

All patients signed informed consent forms.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

Not applicable.

Authors' contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by ZPL, SYW, TL, SC, YL, WX, JT. ZPL wrote the main manuscript text and JT prepared figures 1-3. SYW, TL, SC, YL, WX and JT provided critical revision of the manuscript for intellectual content. All authors read and approved the final manuscript.

Acknowledgements

Not applicable.

Tan R, Lv X, Wu P, Li Y, Dai Y, Jiang B, et al. Learning Curve and Initial Outcomes of Full-Endoscopic Posterior Lumbar Interbody Fusion. Front Surg. 2022;9:890689.
Huang YP, Du CF, Cheng CK, Zhong ZC, Chen XW, Wu G, et al. Preserving Posterior Complex Can Prevent Adjacent Segment Disease following Posterior Lumbar Interbody Fusion Surgeries: A Finite Element Analysis. PLoS One. 2016;11(11):e0166452.
Xue Y, Li S, Wang Y, Zhang H, Cheng L, Wu Y, et al. Unilateral Modified Posterior Lumbar Interbody Fusion Combined With Contralateral Lamina Fenestration Treating Severe Lumbarspinal Stenosis: A Retrospective Clinical Study. Surg Innov. 2023;30(1):73–83.
Yin P, Gao H, Zhou L, Pang D, Hai Y, Yang J. Enhanced Recovery after an Innovative Percutaneous Endoscopic Transforaminal Lumbar Interbody Fusion for the Treatment of Lumbar Spinal Stenosis: A Prospective Observational Study. Pain Res Manag. 2021;2021:7921662.
Liu G, Liu W, Jin D, Yan P, Yang Z, Liu R. Clinical outcomes of unilateral biportal endoscopic lumbar interbody fusion (ULIF) compared with conventional posterior lumbar interbody fusion (PLIF). Spine J. 2023;23(2):271–80.
Hu X, Yan L, Jin X, Liu H, Chai J, Zhao B. Endoscopic Lumbar Interbody Fusion, Minimally Invasive Transforaminal Lumbar Interbody Fusion, and Open Transforaminal Lumbar Interbody Fusion for the Treatment of Lumbar Degenerative Diseases: A Systematic Review and Network Meta-Analysis. Global Spine J. 2023:21925682231168577.
Tang J, Li Y, Wu C, Xie W, Li X, Gan X, et al. Clinical efficacy of transforaminal endoscopic lumbar discectomy for lumbar degenerative diseases: A minimum 6-year follow-up. Front Surg. 2022;9:1004709.
Bartlett MA, Mauck KF, Stephenson CR, Ganesh R, Daniels PR. Perioperative Venous Thromboembolism Prophylaxis. Mayo Clin Proc. 2020;95(12):2775-98.
Zhao XB, Ma HJ, Geng B, Zhou HG, Xia YY. Early Clinical Evaluation of Percutaneous Full-endoscopic Transforaminal Lumbar Interbody Fusion with Pedicle Screw Insertion for Treating Degenerative Lumbar Spinal Stenosis. Orthop Surg. 2021;13(1):328–37.
Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976). 2000;25(22):2940–52; discussion 52.
Bridwell KH, Lenke LG, McEnery KW, Baldus C, Blanke K. Anterior fresh frozen structural allografts in the thoracic and lumbar spine. Do they work if combined with posterior fusion and instrumentation in adult patients with kyphosis or anterior column defects? Spine (Phila Pa 1976). 1995;20(12):1410–8.
Leu HF, Hauser RK. Percutaneous endoscopic lumbar spine fusion. Neurosurg Clin N Am. 1996;7(1):107–17.
Jacquot F, Gastambide D. Percutaneous endoscopic transforaminal lumbar interbody fusion: is it worth it? Int Orthop. 2013;37(8):1507–10.
Morgenstern C, Yue JJ, Morgenstern R. Full Percutaneous Transforaminal Lumbar Interbody Fusion Using the Facet-sparing, Trans-Kambin Approach. Clin Spine Surg. 2020;33(1):40–5.
Wu J, Liu H, Ao S, Zheng W, Li C, Li H, et al. Percutaneous Endoscopic Lumbar Interbody Fusion: Technical Note and Preliminary Clinical Experience with 2-Year Follow-Up. Biomed Res Int. 2018;2018:5806037.
He L, Feng H, Ma X, Chang Q, Sun L, Chang J, et al. Percutaneous endoscopic posterior lumbar interbody fusion for the treatment of degenerative lumbar diseases: a technical note and summary of the initial clinical outcomes. Br J Neurosurg. 2021:1–6.
He LM, Chen KT, Chen CM, Chang Q, Sun L, Zhang YN, et al. Comparison of percutaneous endoscopic and open posterior lumbar interbody fusion for the treatment of single-segmental lumbar degenerative diseases. BMC Musculoskelet Disord. 2022;23(1):329.
Yang H, Cheng F, Hai Y, Liu Y, Pan A. Unilateral biportal endoscopic lumbar interbody fusion enhanced the recovery of patients with the lumbar degenerative disease compared with the conventional posterior procedures: A systematic review and meta-analysis. Front Neurol. 2022;13:1089981.
Li K, Yan TZ, Lu ZA, Wang LH, Hao YK, Lv CL. Utility of Large Diameter Visible Trephine in Percutaneous Endoscopic Lumbar Interbody Fusion: A Technical Report. World Neurosurg. 2022;167:e1253-e60.
Li Y, Dai Y, Wang B, Li L, Li P, Xu J, et al. Full-Endoscopic Posterior Lumbar Interbody Fusion Via an Interlaminar Approach Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Preliminary Retrospective Study. World Neurosurg. 2020;144:e475-e82.
Zhao T, Dai Z, Zhang J, Huang Y, Shao H. Determining the learning curve for percutaneous endoscopic lumbar interbody fusion for lumbar degenerative diseases. J Orthop Surg Res. 2023;18(1):193.
Song X, Ren Z, Cao S, Zhou W, Hao Y. Clinical Efficacy of Bilateral Decompression Using Biportal Endoscopic Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion for the Treatment of Lumbar Degenerative Diseases. World Neurosurg. 2023.
Urits I, Charipova K, Gress K, Schaaf AL, Gupta S, Kiernan HC, et al. Treatment and management of myofascial pain syndrome. Best Pract Res Clin Anaesthesiol. 2020;34(3):427–48.
Galasso A, Urits I, An D, Nguyen D, Borchart M, Yazdi C, et al. A Comprehensive Review of the Treatment and Management of Myofascial Pain Syndrome. Curr Pain Headache Rep. 2020;24(8):43.
Zhu L, Cai T, Shan Y, Zhang W, Zhang L, Feng X. Comparison of Clinical Outcomes and Complications Between Percutaneous Endoscopic and Minimally Invasive Transforaminal Lumbar Interbody Fusion for Degenerative Lumbar Disease: A Systematic Review and Meta-Analysis. Pain Physician. 2021;24(6):441–52.
Ao S, Zheng W, Wu J, Tang Y, Zhang C, Zhou Y, et al. Comparison of Preliminary clinical outcomes between percutaneous endoscopic and minimally invasive transforaminal lumbar interbody fusion for lumbar degenerative diseases in a tertiary hospital: Is percutaneous endoscopic procedure superior to MIS-TLIF? A prospective cohort study. Int J Surg. 2020;76:136–43.
Zhang H, Xu D, Wang C, Zhu K, Guo J, Zhao C, et al. Application of electromagnetic navigation in endoscopic transforaminal lumbar interbody fusion: a cohort study. Eur Spine J. 2022;31(10):2597–606.
Huang X, Gong J, Liu H, Shi Z, Wang W, Chen S, et al. Unilateral biportal endoscopic lumbar interbody fusion assisted by intraoperative O-arm total navigation for lumbar degenerative disease: A retrospective study. Front Surg. 2022;9:1026952.
Wu B, Wei T, Yao Z, Yang S, Yao Y, Fu C, et al. A real-time 3D electromagnetic navigation system for percutaneous transforaminal endoscopic discectomy in patients with lumbar disc herniation: a retrospective study. BMC Musculoskelet Disord. 2022;23(1):57.
Liounakos JI, Basil GW, Urakawa H, Wang MY. Intraoperative image guidance for endoscopic spine surgery. Ann Transl Med. 2021;9(1):92.
Liounakos JI, Wang MY. Lumbar 3-Lumbar 5 Robotic-Assisted Endoscopic Transforaminal Lumbar Interbody Fusion: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown). 2020;19(1):E73-e4.

Table 1 General data of patients in PE-PLIF group and MPLIF group

	PE-PLIF (n=37)	MPLIF(n=58)	P
Gender (Male/Female)	22/15	26/32	0.164
Age (years)	56 (51.5, 63)	58.5 (51, 65.25)	0.691
Disease type			0.073
LS	26	30
LSS	11	28
Surgical level L3/4 L4/5 L5/S1 Follow-up time (months)	8 16 13 15 (13.5, 16)	7 28 23 15 (14,16)	0.461 0.576

Table 2 Surgery-related outcomes in the PE-PLIF group and the MPLIF group

PE-PLIF (n=37)

MPLIF (n=58)

P

Operation time (minutes)

Intraoperative blood loss (milliliter)

Postoperative bedridden time (days)

Postoperative hospitalization time (days)

Modified Macnab

Excellent

Good

Complications

Yes

No

204 (187, 251.5)

90 (60, 120)

2 (1.5, 2)

10 (9, 10)

36 (97.3%)

1 (2.7%)

2 (5.4%)

35 (94.6%)

118 (102.5, 126.25)

200 (150, 285)

5 (5, 6)

12 (11, 13)

57 (98.3%)

1 (1.7%)

0

58 (100%)

＜0.001

0.630

0.075

Table 3 Clinical outcomes of patients in PE-PLIF group and MPLIF group before and after operation

Indictor

PE-PLIF

MPLIF

P

VAS (leg pain)

Preoperative

Postoperative 3 days

Postoperative 1 week

Postoperative 1 month

Postoperative 6 months

Last follow-up

7 (7, 8)

1 (0, 2)**††

0 (0, 0)**††

0 (0, 0) **

8 (7, 9)

1 (1, 1)**††

0 (0, 1)**††

0 (0, 0) **

0.106

0.711

0.080

0.645

0.747

1.000

VAS (low back pain)

Preoperative

Postoperative 3 days

Postoperative 1 week

Postoperative 1 month

Postoperative 6 months

Last follow-up

3 (1.5, 7)

0 (0, 2) *†

0 (0, 0) **

3 (2.75, 5)

3 (2, 4.25)

2 (1.75, 2)*†

0 (0, 0)**††

0 (0, 0) **

0.865

＜0.001

0.375

0.561

0.747

JOA

Preoperative

Postoperative 3 days

Postoperative 1 week

Postoperative 1 month

Postoperative 6 months

Last follow-up

8 (6.5, 9)

27 (24.5, 29)**††

27 (25.5, 29) **

28 (27, 29) **

28 (28, 29) **

29 (28, 29) **

8 (8, 9)

20 (19, 22)*†

28 (25, 29)**††

28 (27, 29) **

29 (28, 29) **

0.174

＜0.001

0.891

0.835

0.424

0.215

ODI

Preoperative

Postoperative 3 days

Postoperative 1 week

Postoperative 1 month

Postoperative 6 months

Last follow-up

16 (8, 35.5)

0 (0, 9)*†

0 (0, 0) **

18.5 (14, 24.75)

16 (11, 24.25)

8 (4, 10)**††

0 (0, 0)**††

0 (0, 0) **

0.617

＜0.001

0.369

0.539

0.759

Note: Compared with the group before surgery, * P < 0.05, ** P < 0.01

Compared with the previous follow-up time point, †P＜0.05，††P＜0.01

VAS: Visual analogue scale, JOA: Japanese orthopaedic association, ODI: Oswestry disability index

No competing interests reported.

Clinical efficacy of percutaneous endoscopic posterior lumbar interbody fusion and modified posterior lumbar interbody fusion in the treatment of lumbar degenerative disease

Status:

Journal Publication

Version 1

Abstract

Figures

Background

Materials and Methods

Results

Discussion

Limitation

Conclusion

Abbreviations

Declarations

References

Tables

Additional Declarations

Status:

Journal Publication

Version 1