Less systemic cytokine response in patients following microendoscopic versus open lumbar discectomy

Abstract

The magnitude of the tissue damage from surgery impacts the trauma response. This response is proportional to the severity of surgical stress. Systemic cytokines are recognized as markers of postoperative tissue trauma. Microendoscopic discectomy (MED) recently has become popular for treating lumbar disc herniations, and is associated with favorable clinical outcomes compared with open discectomy (OD). This study postulates that MED is a less traumatic procedure, and therefore has a lower surgical stress response compared to OD. In this study, a quantitative comparison of the overall effects of surgical trauma resulting from MED and OD was performed through analyzing patient systemic cytokines response. From April, 2002 to June, 2003 consecutive patients who had symptomatic lumbar disc herniations were prospectively randomized to undergo either intracanalicular MED ( N = 10) or OD ( N = 12). In this study, the Vertebroscope System (Zeppelin, Pullach, Germany) was used to perform the endoscopic discectomy procedure in all MED patients. Serum levels of tumor necrosis factor-a (TNF-a), Interleukin-I 0 (IL-I 0). (IL-6), and Interleukin-8 (IL-8) were measured before surgery and at 1.2,4, 8 and 24h after surgery using an enzyme-linked immunosorbent assay. Serum C-reactive protein (CRP) was measured at the same time interval. The results showed the MED patients had shorter postoperative hospital stay (mean, 3.57 f 0.98 vs. 5.92 f 2.39 days, p = 0.025) and less intraoperative blood loss (mean, 87.5 f 69.4 vs. 190 f 115ml, p = 0.042). The operating length, including the set-up time, was longer in the MED group (mean, 109 f 35.9 vs. 72.1 f 17.8min, p = 0.01). The mean size of skin incision made for the MED patients was 1.86 f 0.13cm (range 1.7-2.0cm); and 6.3 f 0.98cm for the O D patients (range 5.5-8cm), p = 0.001. The patients' pain severity of the involved limbs on 10-point Visual Analog Scale before operation in MED group was 7.5 f 0.3 (range 6-9) and 8 f 0.2 (range 7-9) in OD group, p = 0.17; and after surgery, 1.5 f 0.2 (range 1-2) in MED group and 1.4 f 0.1 (range 1-3) in O D group, p = 0.9 1. CRP levels peaked at 24h in both groups, and OD patients displayed a significantly greater postoperative rise in serum CRP (mean, 27.78 & 15.02 vs.13.84 f 6.25mg/l, p = 0.026). Concentrations of TNF-a, IL-I 0, and IL-8 were detected only sporadically. Serum IL-6 increased less significantly following MED than after OD. In the MED group, IL-6 level peaked 8 h after surgery, with the response statistically less than in the open group (mean, 6.27 f 5.96 vs. 17.18 f 11.60pg/ml, p = 0.025). A statistically significant correlation was identified between IL-6 and CRP values ( r = 0.79). Using the modified MacNab criteria, the clinical outcomes were 90% satisfactory (9/10) in MED patients and 91.6% satisfactory (1 1/12) in O D patients at a mean 18.9 months (range 10-25) follow-up. Based on the current data, surgical trauma, as reflected by systemic IL-6 and CRP response, was significantly less following MED than following O...

Operative results and learning curve: microscope-assisted tubular microsurgery for 1- and 2-level discectomies and laminectomies

“…Measuring various serum markers of tissue trauma such as C-reactive protein and systemic cytokines after microendoscopic versus open lumbar discectomy and decompression procedures demonstrates that microendoscopic surgery is associated with a lower level of inflammatory parameters, suggesting decreased invasiveness. 5,13,22,23 Since 2004, we have exclusively used tubular retractors for 1-and 2-level microscope-assisted decompressive surgery in the lumbar spine. In this study, we summarized our clinical results in 230 consecutive patients treated for lumbar disc herniations, lumbar spinal stenosis, and lumbar facet joint cysts.…”

Tubular microdiscectomy: techniques, complication avoidance, and review of the literature

“…20 In contrast, 2 small randomized controlled trials showed shorter hospital stay for patients treated with tubular microdiscectomy. 17,25 In the short term (8 weeks), there was no difference in RDQ or VAS scores in the study by Arts et al 4 Likewise, there were similar rates of complete recovery and time to complete recovery. During recovery, VAS leg and back and RDQ scores were slightly higher in the tubular group compared with the standard group.…”

“…17,25,29 In contrast, the trial conducted by Ryang et al demonstrated no difference in operating times. 26 Multiple retrospective studies and a meta-analysis support similar operating times for the tubular and standard groups.…”

“…26 Huang et al reported no difference in overall complications in another randomized controlled trial. 17 In contrast, in a randomized controlled trial, Teli et al demonstrated no difference in overall complications in the tubular microdiscectomy group but did demonstrate increased CSF leaks. 29 Of note, no CSF leaks in the tubular group required operative revision, probably due to the largely intact paraspinal musculature, which eliminates potential space for CSF fistulas to persist.…”

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“…Huang et al [4] found that C-reactive protein and interleukin-6 levels were lower in the endoscopic group, suggesting that, with comparable clinical results, the lower systemic insult with minimally invasive surgery may justify its use.…”