Developing consensus for the utilization of endoscopy in lumbar microdiscectomy: phase 1 of a systematic review-informed modified Delphi study

Introduction: Spinal endoscopy has become increasingly popular for the minimally invasive treatment of lumbar disc herniation, a major source of pain and disability in society. Here, we present a systematic review-informed approach (Phase 1) followed by a modified Delphi study (Phase 2) reach a consensus regarding using endoscopy in lumbar microdiscectomy. The data from phase 1 is detailed here.

Methods: An a priori PRISMA review from PudMed, Embase, Scopus and hand searches was performed including 1) lumbar spinal surgery and 2) level 1 a/b and 2a study evidence. Patient data and postoperative pain scoring outcomes were evaluated using multivariate mixed-effects regression modeling.

Results: Of 6891 articles, 5469 unique articles were included for title abstract screening, of which 220 full-text microdiscectomy articles were evaluated. In the final analysis, 87 studies from Asia (75.8%), Europe (8.0%), and North America (6.9%) were included. These included a total of 3238 participants with an average age of 45.8 +/- 11.3, BMI of 24.5 +/- 3.1, and consisting of more males (60.0%). Preoperatively, radicular (36.6%) and focal back (34.1%) pain were the most reported symptoms. L4-5 (50.2%) and L5-S1 (37.7%) were the most frequently operated levels. While complications were rare (1.9%), disc recurrence was the most frequently reported complication (34.2%) followed by infections (29.8%), dural tear (20.2%), and nerve injury (15.8%). At 1 month postop, the visual analog scale (VAS) score for back pain and leg pain both showed statistically significant improvement (2.85 to 2.26; 2.88 to 2.20).

Conclusion : This review suggests patient most frequently selected for endoscopic microdiskectomies are males with slightly overweight BMI, focal symptoms and radiculopathy, and lower lumbar pathology. Improved VAS outcomes after one month were observed. A phase 2 implementation of this study will help reach a consensus regarding patients best suited for endoscopic lumbar microdiscectomy.