Comparison Of Tissue Damages Caused By Endoscopic Lumbar Discectomy And Traditional Lumbar Discectomy

Background:Surgery is a special trauma, themagnitude of the tissue damage from surgery impacts the traumatic response, This response is proportional to the severity of surgical stress. percutaneous endoscopic lumbar discectomy (PELD) recently become more and more popular for treating Lumbar Disc Hemiation (LDH) because of the less postoperative pain, less bleed, shorter hospital stay, and is associated with good clinical outcomes compared with Open Discectomy(OD). The spinal musculoskeletal system had to be destroyed in the open surgery, which could easily produce neural adhesion, spinal structural damages, instability and other complications. Therefore, the caused trauma could lead to a series of reactions in vivo, such as:ascent of stress hormones, production of pro-inflammatory cytokines, as well as abnormal metabolic phenomenon, such as:lipolysis or hyperglycemia. And the production of systemic cytokines caused by tissue damages could produce a series of adverse reactions more often to the important organs in human immune system. The minimally invasive surgery aimed to achieve the least amount of trauma to human body by changes of special instruments (such as endoscopes, laser, etc.) and progresses of surgical technologies, so as to reduce the damage of human organs and immune system caused by systemic cytokines due to the tissue damage from this surgery. Therefore, the volume of production of systemic cytokines could be used to assess the postoperative tissue damages. Percutaneous endoscopic lumbar discectomy (PELD) was a new type of spinal minimally invasive surgery in recent years, which needed not general anesthesia and with different surgery way and method from the traditional surgery. Compared to the traditional open lumbar discectomy (OD), PELD had the same clinical curative effect, but there were no objective experimental data to confirm that PELD could cause less tissue damages than the traditional surgery. This study aimed to compare the clinical results (including intraoperative and postoperative blood loss, hospital stay, wound size, VAS, postoperative satisfaction, how long to return to work) of percutaneous endoscopic lumbar discectomy (PELD) and traditional open lumbar discectomy (OD) and analyze preoperative and postoperative changes of systemic cytokines to confirm PELD could cause less damages to human tissues than the traditional surgery, with quicker recovery time and shorter hospital stay in patients. PELD had a very clear promotional value in clinical.Objective:This study aimed to compare the clinical efficacies of percutaneous endoscopic lumbar discectomy (PELD) and traditional open lumbar discectomy (OD), postoperative changes of CRP, CPK and systemic cytokines as well as tissue damages.Methods:20patients with symptomatic disc herniation from October2010to April2011were included in this prospective study. They were randomly divided into two comparison groups, percutaneous endoscopic lumbar discectomy group and traditional lumbar discectomy group, with10patients in each group. The indication for this surgery was herniated disk compressing the spinal nerves. The patients, which were invalid after three months of conservative treatment, were excluded, with following characters①cauda equina syndrome, nerve,②spinal instability,③serious motor nerve damages,④systemic diseases, such as diabetes and hepatic diseases,⑤infectious diseases,⑥recurrent disc herniation. This study was conducted in accordance with the declaration of Helsinki. This study was conducted with approval from the Ethics Committee of the Peoples Hospital of Sanshui District, Foshan. Written informed consent was obtained from all participantsPercutaneous endoscopic lumbar discectomy:The patients underwent local anesthesia in the prone position on the see-through operating table. Additional2-5μg/kg Fentanyl was added to alleviate the pain and maintain the sober situation in patients to communicate to the doctor. The joimax lumbar endoscopic system was used, with an external diameter of7mm and pipeline of3.1mm. Along the import pathways, the spinal coordinate direction was confirmed with10-14cm far from the center line mostly from the rear lateral position. The guide needle was inserted at an angle of10～25degrees to the horizontal plane followed by the pipeline into the periphery of intervertebral foramen and after cutting open a5-7mm wound on the skin. The spinal endoscope was put into the relevant position. The rear pathway was applied in the L5-S1and some free herniated discs. All processes were under the C-arm fluoroscopy. The catheter was put in the lesion position. Ellman bipolar radiofrequency was used for hemostasis and vaporizing tissues and Ho-Yag laser was used for assisted resection of some proliferated bone and herniated disc. At the same time, the intervertebral disc clips with different sizes were used to clip out of the loose herniated nucleus pulposus.Traditional surgery:The intervertebral discs were excised from spinal laminectomy under general anesthesia.Index detection and surgical assessment:The intraoperative and postoperative blood loss, hospital stays and wound size of patients in the two groups were recorded. Enzyme-Linked immunosorbent assay (ELISA) was used to measure preoperative and postoperative1h,6h,12h,24h and48h changes of IL-1β, IL-6, IL-8, IL-10, CRP, CPK, etc. Visual Analog Scale (VAS) and Modified MacNab Criteria were used to evaluate the postoperative results.Results:The overall results showed PELD group had less blood loss (mean8.35±2.99vs.99.0±22.33ml P<0.01), less hospitastay(1.9±0.74vs.5.6±1.26days P<0.01), less skin incision size(0.51±0.02vs.4.90±1.29cm P<0.01)than OD group. Using the modified MacNabcriteria, the clinical outcomes were90%(9/10) in PELD and90%(9/10) in OD group at6months postoperative follow up. Meanwhile, the pain index (preoperative VAS) was7.4±0.8(range6-9) in the endoscopic group and7.6±0.9(range7-9) in the open surgery group, P>0.05In addition, the postoperative pain index was1.8±0.79(range1-3) in the endoscopic group and1.9±0.74in the open surgery group, P>0.05. CRP level showed significantly difference at24hours and48hours between two group (24hr:1.84±0.74mg/dl vs.0.18±0.09mg/dl P<0.01,48hr:2.61±0.93mg/dl vs.0.10±0.04mg/dl P<0.01). CPK level also showed statistically significant difference between two groups (P<0.01).1hr:64.28±4.69vs.78.03±7.17, P<0.01), postoperative6hr:220.54±23.49vs.105.05±17.23,P<0.01. postoperative12hr:298.11±26.03vs.l21.82±22.03,P<0.01.postoperative48h24hr:270.87±43.50vs.123.56±13.08,P<0.01),postoperative48hr:185.5±21.06vs.102.41±14.68, P<0.01. Serum IL-6level showed statistically significant difference between two group after6hours post-operation.6hr (0.87±0.05vs.0.26±0.05P<0.01),12hr (0.93±0.12vs.0.22±0.07, P<0.01), postoperative24hr(0.98±0.09vs.0.26±0.05, P<0.01), postoperative48hr (1.07±0.10vs.0.25±0.06, P<0.01). The systemic IL-6, CRP and CPK was significantly less following.Conclusion:The endoscopic discectomy surgery had less damage to human tissues than the traditional open surgery. PELD had a clear promotional value in clinical.