Surgical Strategy for Lumbar Disc Herniation based on the MSU Classification: Percutaneous Endoscopic Lumbar Discectomy versus Transforaminal Lumbar Interbody Fusion: A 5-year Retrospective Study

Abstract

Objective: Currently, there is no established guideline on whether to opt for percutaneous endoscopic lumbar discectomy (PELD) or traditional transforaminal lumbar interbody fusion (TLIF) surgery based on specific types of lumbar disc herniation (LDH). Based on the Michigan State University (MSU) classification system, this study conducted a medium- to long-term follow-up analysis of two surgical methods over 5 years for the first time, aiming to provide empirical evidence to assist in making more informed decisions before surgery for LDH treatment.

Methods: This was a retrospective study that included 273 patients with single-level LDH who underwent PELD or TLIF treatment at our hospital between January 1, 2016, and December 31, 2018. Detailed metrics included preoperative and postoperative visual analogue scale (VAS) scores and Oswestry disability index (ODI) at 1-day, 1-week, 1-year, and 5-year follow-ups. Complications, recurrences, and 5-year postoperative modified MacNab criteria scores were also recorded. Statistical methods included independent sample t-tests, repeated measures analysis of variance (ANOVA), and χ² tests.

Results: Classified into seven groups according to the MSU classification, it was found that there was an improvement in the VAS and ODI scores at four postoperative follow-ups (p < 0.001). PELD showed better results than TLIF in reducing pain and improving the ODI scores in the classifications of 3B, 2B, and 2C (p < 0.05). TLIF demonstrated consistent superiority over PELD in 2A, 2AB, 3A, and 3AB classifications (p < 0.05). The total recurrence rate in the PELD group (11.05%) within 5 years after surgery was higher (p < 0.05) than that in the TLIF group (3.96%). These were mainly concentrated in the 2A, 2AB, 3A, and 3AB types. Moreover, the rate of excellent and good outcomes in the PELD was higher than in the TLIF but no significant difference (χ² = 1.0568, p = 0.5895).

Conclusion: This study suggests that PELD and TLIF may relieve LDH, but have advantages under different MSU classifications. The MSU classification has specific guiding significance and could aid in the surgical selection of PELD or TLIF to achieve optimal treatment outcomes for patients with lumbar disc herniation.

Keywords

Lumbar disc herniation / MSU classification / PELD / Retrospective study / TLIF

References

[1] Zhang AS, Xu A, Ansari K, Hardacker K, Anderson G, Alsoof D, et al. Lumbar disc herniation: diagnosis and management. Am J Med. 2023; 136(7): 645–651.

[2] Al Qaraghli MI, De Jesus O. Lumbar disc herniation. StatPearls. Treasure Island, FL: StatPearls Publishing; 2023.

[3] Lew SM, Mehalic TF, Fagone KL. Transforaminal percutaneous endoscopic discectomy in the treatment of far-lateral and foraminal lumbar disc herniations. J Neurosurg. 2001; 94(2 Suppl): 216–220.

[4] Kang TW, Park SY, Oh H, Lee SH, Park JH, Suh SW. Risk of reoperation and infection after percutaneous endoscopic lumbar discectomy and open lumbar discectomy: a nationwide population-based study. Bone Joint J. 2021; 103-B(8): 1392–1399.

[5] Mooney J, Laskay N, Erickson N, Salehani A, Mahavadi A, Ilyas A, et al. General vs local anesthesia for percutaneous endoscopic lumbar discectomy (PELD): a systematic review and meta-analysis. Global Spine J. 2023; 13(6): 1671–1688.

[6] Li Z, Tang J, Hou S, Ren D, Li L, Lu X, et al. Four-year follow-up results of transforaminal lumbar interbody fusion as revision surgery for recurrent lumbar disc herniation after conventional discectomy. J Clin Neurosci. 2015; 22(2): 331–337.

[7] Sousa JM, Ribeiro H, Silva JL, Nogueira P, Consciência JG. Clinical outcomes, complications and fusion rates in endoscopic assisted intraforaminal lumbar interbody fusion (iLIF) versus minimally invasive transforaminal lumbar interbody fusion (MI-TLIF): systematic review and meta-analysis. Sci Rep. 2022; 12(1): 2101.

[8] Patel J, Kundnani V, Raut S, Meena M, Ruparel S. Perioperative complications of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF): 10 years of experience with MI-TLIF. Global Spine J. 2021; 11(5): 733–739.

[9] Mysliwiec LW, Cholewicki J, Winkelpleck MD, Eis GP. MSU classification for herniated lumbar discs on MRI: toward developing objective criteria for surgical selection. Eur Spine J. 2010; 19(7): 1087–1093.

[10] Hosseini B, Taheri M, Sheibani K. Comparing the results of intradiscal ozone injection to treat different types of intervertebral disc herniation based on MSU classification. Interv Neuroradiol. 2019; 25(1): 111–116.

[11] Kaliya-Perumal AK, Luo CA, Yeh YC, Tsai YF, Chen MJW, Tsai TT. Reliability of the Michigan State University (MSU) classification of lumbar disc herniation. Acta Ortop Bras. 2018; 26(6): 411–414.

[12] Faiz KW. VAS–visual analog scale. Tidsskr nor Laegeforen. 2014; 134(3): 323.

[13] Fairbank JC, Pynsent PB. The oswestry disability index. Spine (Phila Pa 1976). 2000; 25(22): 2940–2952; discussion 2952.

[14] Wang H, Yuan H, Yu H, Li C, Zhou Y, Xiang L. Percutaneous endoscopic lumbar discectomy using a double-cannula guide tube for large lumbar disc herniation. Orthop Surg. 2022; 14(7): 1385–1394.

[15] Mayer HM, Brock M. Percutaneous endoscopic lumbar discectomy (PELD). Neurosurg Rev. 1993; 16(2): 115–120.

[16] Li H, Jiang C, Mu X, Lan W, Zhou Y, Li C. Comparison of MED and PELD in the treatment of adolescent lumbar disc herniation: a 5-year retrospective follow-up. World Neurosurg. 2018; 112: e255–e260.

[17] Li B, Wang TH, Huang Y, Fan YM, Yu H, Li AQ, et al. Correlation between disc imaging observations and clinical efficacy after percutaneous endoscopic lumbar discectomy: a 1-year follow-up study. Orthop Surg. 2024; 16: 851–863.

[18] Luo M, Wang Z, Zhou B, Yang G, Shi Y, Chen J, et al. Risk factors for lumbar disc herniation recurrence after percutaneous endoscopic lumbar discectomy: a meta-analysis of 58 cohort studies. Neurosurg Rev. 2023; 46(1): 159.

[19] Prabhu MC, Jacob KC, Patel MR, Pawlowski H, Vanjani NN, Singh K. History and evolution of the minimally invasive transforaminal lumbar interbody fusion. Neurospine. 2022; 19(3): 479–491.

[20] Harms J, Rolinger H. A one-stager procedure in operative treatment of spondylolistheses: dorsal traction-reposition and anterior fusion (author’s transl). Z Orthop Ihre Grenzgeb. 1982; 120(3): 343–347.

[21] Ge DH, Stekas ND, Varlotta CG, Fischer CR, Petrizzo A, Protopsaltis TS, et al. Comparative analysis of two transforaminal lumbar interbody fusion techniques: open TLIF versus Wiltse MIS TLIF. Spine (Phila Pa 1976). 2019; 44(9): E555–E560.

[22] Lin CH, Huang YH, Lien FC, Wu CY, Chao LY. Percutaneous endoscopic lumbar discectomy versus open lumbar microdiscectomy for treating lumbar disc herniation: using the survival analysis. Tzu Chi Med J. 2023; 35(3): 237–241.

[23] Li YW, Wang HJ, Wang YS, Cui W, Zhou P, Li C. Comparison of percutaneous endoscopic lumbar discectomy versus transforaminal lumbar interbody fusion in treating upper lumbar disc herniation. Zhonghua Yi Xue za Zhi. 2018; 98(2): 113–116.

[24] Hammad A, Wirries A, Ardeshiri A, Nikiforov O, Geiger F. Open versus minimally invasive TLIF: literature review and meta-analysis. J Orthop Surg Res. 2019; 14(1): 229.

[25] Xue J, Song Y, Liu H, Liu L, Li T, Gong Q. Minimally invasive versus open transforaminal lumbar interbody fusion for single segmental lumbar disc herniation: a meta-analysis. J Back Musculoskelet Rehabil. 2021; 35: 505–516.

[26] Cao J, Huang W, Wu T, Jia JY, Cheng X. Percutaneous endoscopic lumbar discectomy for lumbar disc herniation as day surgery-short-term clinical results of 235 consecutive cases. Medicine (Baltimore). 2019; 98(49): e18064.

[27] Dave BR, Marathe N, Mayi S, Degulmadi D, Rai RR, Patil S, et al. Does conventional open TLIF cause more muscle injury when compared to minimally invasive TLIF?-a prospective single center analysis. Global Spine J. 2024; 14(1): 93–100.

[28] Wong AP, Smith ZA, Stadler JA, Hu XY, Yan JZ, Li XF, et al. Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF): surgical technique, long-term 4-year prospective outcomes, and complications compared with an open TLIF cohort. Neurosurg Clin N Am. 2014; 25(2): 279–304.

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2024 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.