Full endoscopic on par with open discectomy for sciatica

Percutaneous transforaminal endoscopic discectomy (PTED) is as effective as open microdiscectomy in alleviating leg pain caused by lumbar disc herniation, results of a trial have shown. PTED can thus be considered as an alternative to open microdiscectomy in the treatment of sciatica.

“PTED resulted in more favourable results for self-reported leg pain, back pain, functional status, quality of life, and recovery,” the researchers said. “These differences, however, were small and may not reach clinical relevance.”

A multicentre randomized controlled trial was conducted in four hospitals in the Netherlands. A total of 613 patients aged 18‒70 years with at least 6 weeks of radiating leg pain caused by lumbar disc herniation were included. The researchers included a predetermined set of 125 patients receiving PTED who were the learning curve cases performed by surgeons who did not do PTED prior to the trial.

Of the remaining participants, 179 were randomized to PTED and 309 to open microdiscectomy. Self-reported leg pain, the primary outcome, was measured using a 0‒100 visual analogue scale (VAS) at 12 months, assuming a noninferiority margin of 5.0. Patients in the PTED learning curve were not included in the primary analyses.

At 12 months, PTED patients reported a statistically significantly lower VAS score for leg pain (median 7.0, interquartile range [IQR] 1.0‒30.0) than did those treated with open microdiscectomy (median 16.0, IQR 2.0‒53.5; between-group difference, 7.1, 95 percent confidence interval, 2.8‒11.3). The PTED group also had less blood loss, shorter length of hospital admission, and earlier timing of postoperative mobilization compared to the open microdiscectomy group. [BMJ 2022;376:e065846]

Likewise, secondary outcomes such as the Oswestry Disability Index, VAS for back pain, health-related quality of life, and self-perceived recovery were more favourable with PTED. Within a year, however, nine patients (5 percent) in the PTED group and 14 (6 percent) in the open microdiscectomy group had repeat surgery.

Of note, these findings were consistent with those of per-protocol analysis and sensitivity analyses, including patients of the learning curve.

A recent meta-analysis comparing PTED with open microdiscectomy in the treatment of sciatica also reported similar results, with moderate-quality evidence for no between-group difference in leg pain reduction or functional status in the long term. [Spine (Phila Pa 1976) 2021;46:538-549]

However, most of the studies in this meta-analysis did not employ an adequate randomization procedure. Three studies had a low risk of selection bias but had some form of attrition or reporting bias. [J Bone Joint Surg Am 1999;81:958-965; Eur Spine J 2017;26:847-856; World Neurosurg 2020;138:e867-875]

“The results of the [present] study show that PTED is noninferior to open microdiscectomy in the treatment of leg pain but also that no meaningful clinical differences in patient reported outcomes exist between the procedures,” the researchers said. “Therefore, future decisions on doing lumbar discectomy should consider patients’ preferences for a treatment, the burden of the treatment to the patient, and the costs of the treatment.”