Literature Review
Operative Approaches for Lumbar Disc Herniation: A Systematic Review and Multiple
Treatment Meta-Analysis of Conventional and Minimally Invasive Surgeries
Mohammed Ali Alvi1,2, Panagiotis Kerezoudis1,2, Waseem Wahood1,2, Anshit Goyal1,2, Mohamad Bydon1,2
Key words
- Disc herniation
- Discectomy
- Minimally invasive surgery
- Open surgery
- Patient-reported outcomes
- Spine surgery
- Surgical outcomes
Abbreviations and Acronyms
CI: Confidence interval
MD: Microdiscectomy
MIS: Minimally invasive surgery
OD: Open discectomy
ODI: Oswestry Disability Index
OR: Odds ratio
PD: Percutaneous discectomy
PED: Percutaneous endoscopic discectomy
TD: Tubular discectomy
VAS: Visual analog scale
From the 1Department of Neurosurgery and 2Mayo Clinic
Neuro-Informatics Laboratory, Mayo Clinic, Rochester,
Minnesota, USA
To whom correspondence should be addressed:
Mohamad Bydon, M.D.
[E-mail: mohamad.bydon@gmail.com; bydon.mohamad@
mayo.edu]
Supplementary digital content available online.
Citation: World Neurosurg. (2018) 114:391-407.
https://doi.org/10.1016/j.wneu.2018.02.156
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2018 Elsevier Inc. All
rights reserved.
INTRODUCTION
The history of surgery for lumbar disc her-
niation dates back to either Walter1 in 1929 or
Mixter and Barr2 in 1932, who first described
the procedure, and the technique has since
evolved extensively. Open discectomy
practiced today is a modification of the
technique described by Dr. Grafton J. Love
in 1938, known as the Love technique.3,4
The advent of microscopic or
microdiscectomy (MD), the “gold standard”
of surgical treatment for lumbar disc
herniation5 came in 1967 by Yasargil6 and
was further refined by the orthopedic
surgeon John McCulloch in mid 1990s.7 In
1975, Hijikata et al.8 introduced a
percutaneous posterolateral approach for
WORLD NEUROSURGERY 114: 391-407, JUNE 2018
- BACKGROUND: Minimally invasive surgery (MIS) techniques have emerged
as viable and safe alternatives for lumbar disc herniation, including percuta-
neous discectomy, percutaneous endoscopic discectomy, and tubulardiscectomy
(TD). We present here a systematic review and a multiple-treatment meta-
analysis evaluating the operative outcomes and patient-reported outcomes of
open/microdiscectomy (OD/MD) and all MIS approaches for lumbar disc
herniation.
- METHODS: The PICO approach and PRISMA (i.e., Preferred Reporting Items
for Systematic Reviews and Meta-Analyses) guidelines were followed to query
existing online databases since their inception to 2016, which yielded 14 studies
after we applied the inclusion/exclusion criteria. The Cochrane Collaboration’s
tool for assessing risk of bias in randomized trials was used to assess the risk of
bias in each study was used to assess the risk of bias in each study. Each
outcome was assessed across all studies with the GRADE (i.e., Grading of
Recommendations, Assessment, Development and Evaluations) criteria.
- RESULTS: There were 1707 patients analyzed, with 782 (45.81%) undergoing
OD/MD, 491 (28.76%) undergoing TD, 199 (11.65%) undergoing percutaneous
endoscopic discectomy, and 235 (13.76%) patients undergoing percutaneous
discectomy. TD was found to be associated with significantly worse Oswestry
Disability Index scores (mean difference 1.17, P [ 0.03) whereas OD/MD was
associated with worse Oswestry Disability Index scores compared with all
other approaches (mean difference 2.61, P [ 0.03), significantly longer duration
of stay (mean difference 2.96, P [ 0.04), and more blood loss (mean difference
30.53, P < 0.001). In terms of complications, TD was found to be associated with a
greater rate of overall complications (odds ratio [OR] 1.49, P [ 0.002), greater
incidence of dural tears (OR 1.72 P [ 0.04), and recurrent herniation (OR 2.09,
P [ 0.0007). Finally, OD/MD was associated with significantly lower incidence
of revision surgery (OR 0.53, P [ 0.0007).
- CONCLUSIONS: Our meta-analysis revealed that tubular-discectomy and
percutaneous-endoscopic-discectomy, the most commonly employed MIS tech-
niques for discectomy, can be used as safe alternatives for open discectomy
depending on the preference of the operating surgeon.
accessing the disk space. Since then, many cannula,14 became routine in 1990s, and
adjuncts have been made to this approach, these methods collectively comprise the
including but not limited to nucleotomy,9 percutaneous endoscopic discectomy
thermal ablation intradiscal electrothermal (PED). In 1997, Smith and Foley15 and
therapy annuloplasty, nucleoplasty,10 and introduced the muscle-splitting tubular
chemonucleolysis,11 which are collectively approach, also known as tubular discectomy
referred to as percutaneous discectomy (TD) system, which involves inserting
(PD). The use of an endoscope, endoscope sequential dilators to approach the site of
sheath, and cannula assembly,12 a working pathology and then using a tubular retractor
channel scope,13 or use of an oval to remove the disk. Together these,
www.WORLDNEUROSURGERY.org 391
 LITERATURE REVIEW
MOHAMMED ALI ALVI ET AL. OPERATIVE APPROACHES FOR LUMBAR DISC HERNIATION

approaches are referred to as minimally
invasive surgery (MIS).
To date, there are several clinical trials
comparing one approach to another as
well as systematic reviews and meta-
analyses comparing a particular MIS
approach with OD/MD16-35 or all mini-
mally invasive approaches collectively with
OD or MD.17 Unfortunately, the literature
is ambiguous and heavily studded with
taxonomical errors, making it difficult for
reviewers to draw conclusions. We
present here a systematic review to
compare the patient-reported outcomes,
surgical outcomes, and complications
among open/microdiscectomy, PD, PED,
and TD using a multiple treatment meta-
analyses method.
MATERIALS AND METHODS
Search Strategy
This study was conducted using the Pa-
tient, Intervention, Comparator and
Outcome(PICO), and the Preferred
Reporting Items for Systematic Reviews
and Meta-Analyses (i.e., PRISMA).18 A
comprehensive search of several
databases was conducted from 1965 to
August 22, 2016, in any language. The
databases included Ovid Medline in-
process and other nonindexed citations,
Ovid MEDLINE, Ovid EMBASE, Ovid
Cochrane Central Register of Controlled
Trials, Ovid Cochrane Database of
Systematic Reviews, and Scopus. An
experienced librarian designed the search
strategy with input from the 2 authors
(M.A.A and P.K). The actual strategy is
available in Supplementary Material 1.
Selection Criteria
Inclusion criteria included 1) patients aged
>18 years; 2) confirmed diagnosis of
lumbar disc herniation; 3) at least 1 of the
following outcomes: operative time, blood
loss, hospital stay, complications, and
pre- and postoperative functional and pain
scores by Oswestry Disability Index (ODI)
and visual analog scale (VAS), respectively;
and 4) randomized or quasi-randomized
controlled trials involving a direct
comparative study design. Exclusion
criteria included 1) <10 patients per study
arm; 2) case series and single-arm
prospective cohorts; and 3) editorials,
reviews, and opinion and commentary
articles. Manual search of reference lists
was performed to ensure relevant studies
were not missed. For missing data, we
contacted the authors of those studies and
if a response wasn’t received, we imputed
these values as per the Cochrane
guidelines.19
Data Extraction
Data extraction from articles, tables, and
figures was performed by one reviewer
(M.A.A.) with accuracy of data entry
confirmed by second reviewer (P.K). The
following variables were extracted, as
summarized in the sections below.

Table 1. Risk of Bias Assessment of Included Studies

Random Sequence Allocation Blinding of Participants Blinding of Outcome Incomplete Selective Other
Study Generation Concealment and Personnel Assessment Outcome Data Reporting Bias

Garg et al., 201121 Low Unclear High High Low Low High*
22
Teli et al., 2010 Low Unclear High High High Low Low
23
Ruetten et al., 2008 Low Unclear High Lowy Low Low Low
Pan et al., 201424 Low Unclear High Unclear Low Low Low
Shin et al., 200825 Low Low High High Low Low Low
Righesso et al., 200726 Low Unclear High High Low Low Low
Huang et al., 200527 Lowz Low High High Low Low Low
28
Hermantin et al., 1999 Low Unclear High Lowx Low Low Highk
Mayer and Brock, 199329 Low Low High High Low Low Low
30
Belykh et al., 2016 Low Low High Unclear Low Low Low
Abrishamkar et al., 201531 Low Low High Unclear Low Low High{
Ryang et al., 200832 Low Low High Unclear Low Low Low
33
Chatterjee et al., 1995 Low Low High High Low High# Low
Arts et al., 201134 Low Low Low** Unclear Highyy Low Low

*Dural leaks happened with earlier patients.

yPhysicians assessing outcome were not involved with surgery.
zOne patient of 22 wanted to choose.
xPhysicians assessing outcome were not involved with surgery.
kPhysicians were able to override decision for type of surgery.
{Study was done in one institution in Iran.
#Study acknowledges that they cannot assess outcomes of other percutaneous techniques.
**Double-blind randomized controlled trial among patients.
yyA total of 140 of 216 patients had magnetic resonance imaging, those who are in the primary center.

392 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.02.156

 LITERATURE REVIEW
MOHAMMED ALI ALVI ET AL. OPERATIVE APPROACHES FOR LUMBAR DISC HERNIATION

Table 2. Grading of Recommendations Assessment, Development and Evaluation (GRADE) Assessment of Quality of Evidence
Confidence in
No. No. Risk of Other Relative Effect Estimates
Outcome Studies Patients Bias Inconsistency Indirectness Imprecision Considerations Effect (95% CI) (GRADE)

VAS (leg) at 1 year 6 508 Serious Serious Not serious Not serious Not serious 0.10 (0.42, 0.61) Very low
(MD/OD vs. all others)
VAS (leg) at last follow-up 9 553 Serious Serious Not serious Not serious Not serious 0.11 (0.17, 0.39) Very low
(MD/OD vs. all others)
VAS (back) at last follow up 3 299 Serious Serious Not serious Not serious Not serious 0.06 (0.55, 0.68) Very low
(MD/OD vs. TD)
ODI at 1 year (MD/OD vs. 4 257 Serious Serious Not serious Not serious Not serious 0.51 (3.00, 4.01) Very low
TD and PED)
ODI at last follow-p (MD/OD vs. 5 287 Serious Serious Not serious Not serious Not serious 2.61 (0.88e4.35) Very low
TD and PED)
Length of stay (MD/OD vs. TD 6 82 Serious Not serious Not serious Not serious Not serious 0.95 (0.43e2.09) Low
and PED)
Blood loss (MD vs. TD and PED) 6 226 Serious Serious Not serious Not serious Not serious 30.53 (16.58e44.47) Very low
Total complications (MD/OD vs. 7 1161 Serious Serious Not serious Not serious Not serious 0.96 (0.75e1.22) Very low
TD and PED)
Dural tears (MD/OD vs. 5 1049 Serious Not serious Not serious Not serious Not serious 0.74 (0.44e1.25) Low
TD and PED)
Recurrent herniations 6 1119 Serious Not serious Not serious Not serious Not serious 0.61 (0.42e0.90) Low
(MD/OD vs. TD and PED)
Reoperations (MD/OD vs. 8 578 Serious Serious Not serious Not serious Not serious 0.53 (0.36e0.76) Very low
all others)
VAS (leg) at 1 year 5 335 Serious Serious Not serious Not serious Not serious 0.04 (0.53, 0.45) Very low
(TD vs. MD/OD and PED)
VAS (leg) at last follow up 7 370 Serious Serious Not serious Not serious Not serious 0.01 (0.13, 0.15) Very low
(TD vs. MD/OD and PED)
ODI at 1 year (TD MD/OD 4 179 Serious Not serious Not serious Not serious Not serious 1.17 (0.10e2.24) Low
and PED)
ODI at last follow-up (TD vs. 5 209 Serious Serious Not serious Not serious Not serious 0.40 (3.01, 2.20) Very low
MD/OD and PED)
Total complications (TD vs. 5 736 Serious Not serious Not serious Not serious Not serious 1.49 (1.16e1.92) Low
MD/OD and PED)
Dural tears (TD vs. MD/OD 4 726 Serious Not serious Not serious Not serious Not serious 1.77 (1.03e3.05) Low
and PED)
Recurrent herniations (TD vs. 4 726 Serious Not serious Not serious Not serious Not serious 2.05 (1.36e3.09) Low
MD/OD and PED)
VAS (leg) at last follow-up 3 88 Serious Serious Not serious Not serious Not serious 0.39 (1.02, 0.24) Very low
(PED vs. MD/OD and TD)
Dural tears (PED vs. all others) 3 233 Serious Not Serious Not serious Not serious Not serious 0.33 (0.11e0.95) Low

CI, confidence interval; VAS, visual analog scale; MD/OD, open/microdiscectomy; TD, tubular discectomy; ODI, Oswestry Disability Index; PED, percutaneous endoscopic discectomy.

Covariates. Covariates included methodol- Summary of Outcomes. Primary outcomes Cohort Comparison
ogy data, study design, patient included patient-reported outcomes From the studies reporting patient
demographics, involved levels, symptom- including VAS and ODI. Secondary demographics, pooled means for age, sex
atic as well as radiologic criteria for outcomes of interest included estimated (% male), and number of surgical levels
inclusion or exclusion for the trial, blood loss, length of stay, revision surgery, were calculated via a weighted distribu-
follow-up duration, and assessment and operative complications (any compli- tion. Continuous variables were
intervals. cation, dural tears, recurrent herniation). compared with the 2-sample t test, and

WORLD NEUROSURGERY 114: 391-407, JUNE 2018 www.WORLDNEUROSURGERY.org 393

 LITERATURE REVIEW
MOHAMMED ALI ALVI ET AL. OPERATIVE APPROACHES FOR LUMBAR DISC HERNIATION

available for trials assessing PD, a

separate subgroup analysis was not
possible. All statistical analysis was
conducted with Review Manager Version
5.3.2 (Review Manager [RevMan]
Computer program, Version 5.3., 2014:
The Nordic Cochrane Centre, The
Cochrane Collaboration, Copenhagen,
Denmark).

Evidence Quality and Publication Bias

Assessment
The quality of evidence for each study was
assessed independently by 2 reviewers
(M.A.A. and P.K) using Cochrane Collab-
oration’s tool for assessing risk of bias
(Table 1).36 Each outcome was graded
across all studies using the GRADE
criteria (Grading of Recommendations,
Assessment, Development and
Evaluations; see Table 2). Funnel plot
methodology was used to assess the
interstudy risk of publication bias,
plotting the proportion of an event
against its precision and analyzing for
asymmetry.

RESULTS

Literature Search
Our search strategy identified a total of
2605 studies identified through database
search (Figure 1). After removal of 827
duplicative publications and 1083
nonrandomized controlled trials,
inclusion/exclusion criteria were applied
to abstracts of remaining 695 articles.
This yielded 22 articles that underwent
full-text analysis. Fourteen articles are
included in the current review for both
Figure 1. Flowchart depicting the literature review, search strategy, and qualitative and quantitative analysis.21-34
selection process for including studies for systematic review and Thirteen studies included were single-
meta-analysis. NON-RCTs, nonrandomized controlled trials.
institution randomized clinical trials, and
1 study was a quasi-randomized controlled
clinical trial (Table 3).
the number of surgical levels were greater than 50% considered as substantial
compared with the 2-proportion z test heterogeneity. Because of the unavailabil- Demographics
with statistical significance established ity of raw data, specific analyses for There were 1707 patients analyzed in all
for 2-tailed P < 0.05. confounders could not be performed. studies, with 782 (45.81%) undergoing MD/
Since our analysis involved more than 2 OD, 491 (28.76%) undergoing TD, 199
Meta-Analysis of Clinical Outcomes treatment arms, we followed the guide- (11.65%) undergoing PED, and 235 (13.76%)
The odds ratio, mean difference, or lines enlisted in Cochrane handbook for patients undergoing PD. Comparative fea-
weighted mean difference were used as meta-analysis19 and conducted several tures are included in Tables 3 and 4. Mean age
summary statistics. We tested both fixed direct and indirect subgroup analysis ranged from 38 to 48.1 years in the MD/OD
and random effects model as per needed. comparing MD/open discectomy (OD), group, 37 to 42.7 years in the TD group, 38.9
To estimate the variation across studies, TD, and PED with each other separately. to 42.09 in the PD group, and 39 to 39.8 in
the I2 statistic was used, with values Due to fewer numbers of studies the PED group. Proportion of females

394 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.02.156

 LITERATURE REVIEW
MOHAMMED ALI ALVI ET AL. OPERATIVE APPROACHES FOR LUMBAR DISC HERNIATION

Table 3. Characteristics of Included Studies

Study Country Procedures Compared PED, n TD, n PD, n OD/MD, n Mean Follow-Up

Garg et al., 201121 India Tubular and open/micro NA 55 NA 57 12e18 months

22
Teli et al., 2010 Italy Tubular and open/micro NA 70 NA 142 26 (24e29)
Ruetten et al., 200823 Germany Percutaneous endoscopic and open/ 50 NA NA 50 24 months
micro
Pan et al., 201424 China Percutaneous endoscopic and open/ 10 NA NA 10 No long-term follow-up data
micro
Shin et al., 200825 South Korea Tubular and open/micro NA 15 NA 15 5 days
Righesso et al., 200726 Brazil Tubular and open/micro NA 21 NA 19 36.2 (25e56) for MED and 36
(24e46) for open
Huang et al., 200527 Taiwan Tubular and open/micro NA 10 NA 12 18.9 (10e25)
28
Hermantin et al., 1999 USA Tubular and open/micro NA 30 NA 30 31 months
Mayer and Brock, 199329 Germany Percutaneous endoscopic and open/ 20 NA NA 20 NR
micro
Belykh et al., 201630 Russia Tubular, percutaneous endoscopic, 44 39 NA 48 12 months
and open/micro
Abrishamkar et al., 201531 Iran Percutaneous and open/micro NA NA 100 100 e
Ryang et al., 200832 Germany Tubular and open/micro NA 30 NA 30 16 months
Chatterjee et al., 199533 United Kingdom Percutaneous and open/micro NA NA 31 40 e
34
Arts et al., 2011 The Netherlands Tubular and open/micro NA 166 NA 159 24 months

PED, percutaneous endoscopic discectomy; TD, tubular discectomy; PD, percutaneous discectomy; NA, not available; MED, micro-endoscopic discectomy; NR, not reported.

ranged from to 22% to 66.6% in the MD/OD
group, 34% to 56.6% in the TD group, 18%
to 51% in the PD group, and 26.6% to 40%
in the PED group.
Total Levels
Among the MD/OD group, a total of 774
levels were operated on (9 on L2eL3, 38
on L3eL4, 345 on L4eL5, and 380 on
L5eS1). Within the TD group, a total of
493 levels were operated on (1 on L2eL3,
11 on L3eL4, 219 on L4eL5, 262 on L5e
S1). Within PED, a total of 185 levels
were operated on (9 on L2eL3, 27 on
L3eL4, 85 on L4eL5, 64 on L5eS1).
Within the PD, a total of 247 levels were
operated on (3 were operated on L2eL3,
13 on L3eL4, 156 on L4eL5, and 75 on
L5eS1). This information can be seen in
Table 3.
Primary Outcomes
VAS at 1 Year. All patient reported out-
comes and clinical outcomes have been
summarized in Tables 5 and 6,
respectively. Nine studies reported VAS
leg pain/sciatica scores that could be
used for analysis. Only 4 studies reported
VAS at 1 year. To be more inclusive, we
did a separate analysis of VAS at last
follow-up. Three studies reported VAS
back score. We conducted a separate
analysis for these studies. There was no
significant difference between MD/OD
and all MIS groups (mean difference 0.10,
95% confidence interval [CI] e0.42 to
0.61; studies ¼ 6; I2 ¼ 94%) (Figure 2Ae
B). We could not detect any difference in
VAS at 1 year for TD when compared
with MD/OD and PED (mean difference
e0.04, 95% CI e0.53 to 0.45; studies ¼
5; I2 ¼ 95%) (Figure 2CeD).
Oswestry Disability Index. Five studies re-
ported ODI scores, which could be used
for statistical analysis. Only 3 of these
reported ODI at 1 year and were combined
for a separate analysis. For inclusion, we
did an analysis on ODI at last follow-up.
ODI at 1 Year. There was no statistically
significant difference in ODI at 1 year for
MD/OD compared with TD and PED
(mean difference 0.51, 95% CI 3.00 to
4.01; studies ¼ 4; I2 ¼ 92%) (Figure 3A).
ODI at 1 year was found to be
significantly worse in TD group than
other groups (mean difference 1.17, 95%
CI 0.10e2.24; studies ¼ 4; I2 ¼ 46%,
test for overall effect Z ¼ 2.14, P ¼ 0.03)
(Figure 3B).
ODI at Last Follow-Up. ODI at last follow-
up was found to be significantly greater
and hence worse in MD/OD compared
with TD and PED (mean difference 2.61,
95% CI 0.88e4.35; studies ¼ 5; I2 ¼ 56%
test for overall effect Z ¼ 2.95, P ¼ 0.03)
(Figure 3C).
Secondary Outcomes
Length of Stay. MD/OD group was asso-
ciated with significantly longer length of
stay than TD and PED (mean difference
2.96, 95% CI 0.20e5.72; studies ¼ 6; I2 ¼
99%, test for overall effect Z ¼ 2.10, P ¼
0.04) (Figure 4).
Estimated Blood Loss. MD or OD was
found to associated with significantly
more blood loss than TD and PED (mean
difference 30.53, 95% CI 16.58e44.47;
studies ¼ 7; I2 ¼ 97%, test for overall

WORLD NEUROSURGERY 114: 391-407, JUNE 2018 www.WORLDNEUROSURGERY.org 395


MOHAMMED ALI ALVI ET AL.
Table 4. Description of Technique in Included Studies
Study
Garg et al., 201121
Teli et al., 201022
Ruetten et al., 200823
Pan et al., 201424
Shin et al., 200825
Righesso et al., 200726
Huang et al., 200527
Hermantin et al., 199928
Mayer and Brock, 199329
30
Belykh et al., 2016
endoscope was fastened in the
Abrishamkar et al.,
201531
Ryang et al., 200832
Chatterjee et al., 199533
Arts et al., 201134
PED, percutaneous endoscopic discectomy; TD, tubular discectomy; PD, percutaneous discectomy; OD/MD, open/microdiscectomy; NA, not available; MED, micro-endoscopic discectomy; APLD,
automated percutaneous lumbar discectomy.
396 www.SCIENCEDIRECT.com
OPERATIVE APPROACHES FOR LUMBAR DISC HERNIATION
Description of PED Description of TD
NA The open (laminotomy) discectomy
was performed in a standard fashion
NA Laminotomy, medial facetectomy
when needed and nerve root
retraction followed by discectomy
were all performed identically in
the 3 groups
Transforaminal procedure with NA
access as lateral as possible.
Percutaneous endoscopic NA
lumbar discectomy
NA A guide pin was inserted then the
first dilator was passed over the
guide pin, and then the guide pin
was removed so as not to penetrate
the dura mater. The remaining
dilators were passed sequentially.
NA Microendoscopic technique as
described by Foley and Smith15
NA Microendoscopic
technique
NA Arthroscopic microdiscectomy was
performed with the use of an oval 5
mm  8 mm cannula
Percutaneous endoscopic NA
A 2.0- to 2.5-cm longitudinal Procedure performed under
incision was made 1e2 cm visualization of 0-30 degrees
lateral to the midline. The endoscopes in addition to
microsurgical visualization
working space.
NA NA
NA The lumbodorsal fascia was bluntly
dissected and the trocar together
with the enclosed mandrin, was
gently screwed in. The mandrin was
removed and the handle attached
to the trocar.
NA NA
a 2-mm nonflexible automated
NA In case of tubular discectomy, the
skin was retracted laterally, and the
guidewire and sequential dilators
(METRx, Medtronic, Minneapolis,
Minnesota, USA) were placed.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.02.156
LITERATURE REVIEW
Description of PD Description of OD/MD
NA For MED, the paraspinal
approach was used
NA Laminotomy, medial
facetectomy when needed and
nerve root retraction followed
by discectomy were all
performed identically
in the 3 groups
NA Conventional microsurgical
operation with paramedian
access
NA Traditional open lumbar
discectomy
NA Standard surgical procedures,
consisting of a hemipartial
laminectomy and discectomy,
were performed according to
the method described by
Love.10
NA Using Caspar’s technique
modified only by the use of
surgical magnifying loupe and
a halogen headlight instead of
the surgical microscope
NA Open lumbar discectomy
NA The open laminotomy and
discectomy was performed in
a standard fashion
NA Microdiscectomy
NA Interlaminar approach
Percutaneous nucleoplasty Traditional open discectomy
NA Standard open discectomy
APLD was performed with Standard technique via a 2-cm
incision and transligamentous
suction nucleotome approach
NA Conventional microdiscectomy
was performed by ipsilateral
paravertebral muscle
retraction. The herniated disk
was removed by the unilateral
transflaval approach
 LITERATURE REVIEW
MOHAMMED ALI ALVI ET AL. OPERATIVE APPROACHES FOR LUMBAR DISC HERNIATION

Table 5. Summary of Patient-Reported Outcomes

VAS (Leg) VAS (Leg) at VAS (Back) at ODI at Last
Study Eligible, n at 1 Year Last Follow-Up Last Follow-up ODI at 1 Year Follow-Up

Open or microscopic discectomy

Chatterjee et al., 199533 40
29
Mayer and Brock, 1993 20
Garg et al., 201121 57
Pan et al., 2014 24
10 1.9  0.74
23
Ruetten et al., 2008 100
Righesso et al., 200726 19 0.75  0.8 0.75  0.8 8  6.9 12.5  8.6
Ryang et al., 2008 32
30 12  18.8
Arts et al., 2011 34
159 1.75  1.9 1.4  0.18 1.9  0.19
Belykh et al., 201630 48 1.9  0.6 1.9  0.6 21  5.2 21  5.2
Abrishamkar et al., 2015 31
100 2.08  1.55 2.08  1.55
Teli et al., 201022 142 11 21 1.5  1 13  4 15.5  5.5
Shin et al., 2008 25
15 2.4  2.1 3.6  1.1
28
Hermantin et al., 1999 30
Huang et al., 200527 12 1.4  0.1
Tubular endoscopic discectomy
Garg et al., 201121 55
Righesso et al., 2007 26
21 0.75  0.8 0.75  0.8 14  9.2 10.5  6.35
Ryang et al., 2008 32
30 12  12
Arts et al., 201134 166 2.25  1.8 1.53  0.17 2.35  0.19
Belykh et al., 201630 44 1.1  0.4 1.1  0.4 19  4 19  4
Teli et al., 201022 70 11 21 21 14  4 14  6
Shin et al., 2008 25
15 2.5  1.6 1.9  1.1
Huang et al., 2005 27
10 1.5  0.2
Percutaneous endoscopic discectomy
Pan et al., 201424 10 1.8  0.79
23
Ruetten et al., 2008 100
Belykh et al., 201630 39 1  0.5 1  0.5 16  3.4 16  3.4
28
Hermantin et al., 1999 30
Percutaneous discectomy
Chatterjee et al., 199533 31
Abrishamkar et al., 2015 31
100 2.9  2.33 2.9  2.33

VAS, visual analog scale; ODI, Oswestry Disability Index.

effect Z ¼ 4.29, P  0.001) (Figure 5A). TD overall effect Z ¼ 2.82, P ¼ 0.005) complications, dural tears, recurrent her-
was found to be associated with (Figure 5B). niation, and redo surgery for analysis.
significantly less blood loss compared Other complications reported included
with MD/OD and PED (mean Complications wound infections, worsening or persistent
difference 12.91, 95% CI 21.89 Seven studies reported complications. We symptoms, wrong level surgery, and he-
to 3.93; studies ¼ 6; I2 ¼ 92%, test for included the total number of matoma formation.

WORLD NEUROSURGERY 114: 391-407, JUNE 2018 www.WORLDNEUROSURGERY.org 397

 LITERATURE REVIEW
MOHAMMED ALI ALVI ET AL. OPERATIVE APPROACHES FOR LUMBAR DISC HERNIATION

Table 6. Summary of Clinical Outcomes and Complications

Total Recurrent
Study Eligible, n Blood Loss Length of Stay Complications Dural Tears Herniations Reoperations

Open or microscopic discectomy

Chatterjee et al., 199533 40 1
29
Mayer and Brock, 1993 20
Garg et al., 201121 57 12  3 0
Pan et al., 2014 24
10 99  23 5.6  1.26
23
Ruetten et al., 2008 100 12 10
Righesso et al., 200726 19 135.25  126.75 3.3  1.2
Ryang et al., 200832 30 63.8  86.8 4.4  2.8 6 2 3 4
Arts et al., 2011 34
159 3.3  1.1 27 7 17 28
Belykh et al., 201630 48 45  5.7 71 8 11
Abrishamkar et al., 201531 100
Teli et al., 201022 142 12 4 5 5
Shin et al., 2008 25
15 34  11
28
Hermantin et al., 1999 30 1 1
Huang et al., 200527 12 190  115.1 5.92  2.39 1
Mayer and Brock, 199329 20 1
Tubular endoscopic discectomy
Garg et al., 201121 55 31 1
Righesso et al., 2007 26
21 202.5  199.21 1  0.63
Ryang et al., 200832 30 26.2  29.7 4  2.3 2 0 1 2
Arts et al., 2011 34
166 3.3  1.2 31 14 28 40
Belykh et al., 201630 44 40  5.7 64 7 16
Teli et al., 201022 70 11 6 8 8
Shin et al., 2008 25
15 35  9
Huang et al., 200527 10 87.5  69.4 3.57  0.98 1
Percutaneous endoscopic discectomy
Mayer and Brock, 199329 20
Pan et al., 201424 10 8.35  2.99 1.9  0.74
23
Ruetten et al., 2008 100 3 6 7
Belykh et al., 201630 39 45  5.7 26 2 4
Hermantin et al., 199928 30 1 0 0
29
Mayer and Brock, 1993 20 3
Chatterjee et al., 199533 31
Abrishamkar et al., 201531 100
Percutaneous discectomy
Chatterjee et al., 199533 31 20
31
Abrishamkar et al., 2015 100

398 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.02.156

 LITERATURE REVIEW
MOHAMMED ALI ALVI ET AL. OPERATIVE APPROACHES FOR LUMBAR DISC HERNIATION

Figure 2. (A) Forest plot comparing visual analog scale (VAS) leg pain at 1
year between microdiscectomy/open discectomy (MD/OD) and all others,
and subgroup analyses. (B) Funnel plot for comparison of VAS leg pain at 1
year between MD/OD and all minimally invasive surgery groups and
subgroup analyses. (C) Forest plot comparing VAS leg pain at 1 year
between tubular discectomy and all others, and subgroup analyses. (D)
Funnel plot for comparison of VAS leg pain at 1 year between tubular
discectomy and all others and subgroup analyses. SD, standard deviation;
CI, confidence interval.

Any Complication. There was no statisti-
cally significant difference in number of
complications in MD/OD compared with
TD and PED (odds ratio [OR] 0.96, 95% CI
0.75e1.22; studies ¼ 7; I2 ¼ 54%). How-
ever, MD/OD was found to be associated
with significantly more complications
when compared with PED (OR 0.96, 95%
CI 0.75e1.22; studies ¼ 7; I2 ¼ 54%, test
for overall effect Z ¼ 0.37, P ¼ 0.04)
(Figure 6A).
TD was found to be associated with a
greater number of complications than
MD/OD and PED (OR 1.49, 95% CI 1.16e
1.92; studies ¼ 5; I2 ¼ 24% P ¼ 0.002).
Subanalysis also revealed that TD is asso-
ciated with more complications than PED
(OR 2.05, 95% CI 1.23e3.40, studies ¼ 1;
P ¼ 0.006) (Figure 6B).
Dural Tears. There was no statistically
significant difference in incidence of dural
tears between MD/OD and all others (OR
0.74, 95% CI 0.44e1.25; studies ¼ 5; test
for overall effect Z ¼ 1.13, I2 ¼ 19%,
P ¼ 0.26) (Figure 6C). TD was found to be
associated with significantly more dural
tears than other groups (OR 1.77, 95% CI
0.99e2.97; studies ¼ 4; I2 ¼ 0% test for
overall effect Z ¼ 2.07, P ¼ 0.04)
(Figure 6D). Dural tears were significantly
less in PED as compared with other
approaches (OR 0.33, 95% CI 0.11e0.95;
233; studies ¼ 3; I2 ¼ 0% test for overall
effect Z ¼ 2.06, P ¼ 0.04) (Figure 6E).
Recurrent Herniation. MD/OD was found to
be associated with significantly lower rates
of recurrent herniations compared with
TD and PED (OR 0.61, 95% CI 0.42e0.90;
studies ¼ 6; I2 ¼ 20%, P ¼ 0.01)
(Figure 6F). TD was found to be associated
with significantly more recurrent
herniations when compared with all
others (OR 2.05, 95% CI 1.36e3.09;
studies ¼ 4; I2 ¼ 5%, test for overall
effect Z ¼ 3.43 P < 0.001) (Figure 6G).
Revision Surgery. MD/OD was associated
with significantly less incidence of revision
surgery when compared with all other
approaches (OR 0.53, 95% CI 0.36e0.76;
studies ¼ 8; I2 ¼ 67%, test for overall
effect Z ¼ 3.95, P < 0.001) (Figure 6H).
DISCUSSION
The current literature on operative
approaches for lumbar disc herniation
compares minimally invasive approach as
a group with OD/MD and is studded with
taxonomical ambiguity, making it difficult
for a reviewer to appreciate the exact
approach. As the use of MIS gains favor
from more and more spine surgeons,35 it’s
imperative that we discuss each of these
techniques in the light of all the clinical
trials over the past 2 decades. In this

WORLD NEUROSURGERY 114: 391-407, JUNE 2018 www.WORLDNEUROSURGERY.org 399

 LITERATURE REVIEW
MOHAMMED ALI ALVI ET AL. OPERATIVE APPROACHES FOR LUMBAR DISC HERNIATION

Figure 3. (A) Forest plot comparing Oswestry Disability Index others and subgroup analyses. (C) Forest plot comparing ODI at
(ODI) at 1 year between microdiscectomy/open discectomy last follow-up between MD/OD vs. all others and subgroup
(MD/OD) vs. all others and subgroup analyses. (B) Forest plot analyses.
comparing ODI at 1 year between tubular discectomy and all

400 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.02.156


MOHAMMED ALI ALVI ET AL.
Figure 4. Forest plot comparing length of stay between the microdiscectomy/open discectomy (MD/OD) group and all others and
subgroup analyses.
manuscript, we have made an effort to
weigh each technique against each other
in the form of a multiple-treatment
meta-analysis.
In terms of patient-reported outcomes,
our meta-analysis could not detect any
significant difference in VAS leg pain
score at 1 year among any of the
approaches. Rasouli et al.17 found that
MIS discectomy was associated with
more severe leg pain based on VAS score
at 1 year, when compared with MD/OD
(mean difference 0.13, 95% CI 0.09e
0.16, effect estimate Z ¼ 6.81 P  0.001).
This result agrees with our own after we
excluded Belykh et al.30 It may be
implausible to make a conclusive
statement on this, given the sensitivity of
the data as demonstrated by the change
in effect estimate after excluding Belykh
et al.30 However, our results, which prove
noninferiority of MIS surgeries, could
also potentially reflect the better
adaptation to minimally invasive
discectomy over the years leading to
Belykh et al,30 yielding superior results in
terms of outcome when compared with
MD/OD.
For ODI, our results showed that TD
was associated with significantly greater
ODI scores at last follow-up. Interestingly,
at last follow-up, results show that it was
MD/OD that was now associated with
significantly worse ODI scores. Previous
reviews have reported that there is no
significant difference between MD/OD
WORLD NEUROSURGERY 114: 391-407, JUNE 2018
OPERATIVE APPROACHES FOR LUMBAR DISC HERNIATION
and MIS surgery in terms of postoperative
disability scores.16,17,37 We have controlled
for all possible discrepancies and only
reported studies that reported complete
data. Although larger and higher quality
trials have yielded similar results in terms
of patient-reported outcomes between
MD/OD and MIS, the pooled data still
tend to be sensitive.
For surgical outcomes, postoperative
length of stay was found to be significantly
shorter in MIS techniques than in MD/OD.
Although the largest trial in this analysis
(Teli et al.22) failed to detect any
significance, the results in other studies
as well as other reviews have provided
similar conclusions.16,37 Our meta-
analysis also revealed that MIS surgeries
are associated with significantly less blood
loss than MD/OD. This has also been
consistent in other reviews.16,17,37 Such
results may be considered intuitive since
MIS techniques involve less muscle atro-
phy, shorter incisions, and significantly
less blood loss. These factors collectively
also result in shorter hospital stays.
For complications, TD was found to be
associated with significantly greater rate of
overall complications. Looking at individ-
ual complications, we found that TD was
associated with a significantly greater
incidence of dural tears than other
techniques. Rasouli et al.17 reported no
statistical difference in incidence of dural
tears between MD/OD and MIS
techniques. Our results also revealed that
www.WORLDNEUROSURGERY.org
LITERATURE REVIEW
MD/OD was associated with significantly
lower incidence of recurrent herniation
when compared with MIS techniques,
and TD was associated with a greater
incidence of recurrent herniation when
compared with all others. These results
are consistent with previous reviews.17
Lastly, we found that MD/OD had
significantly lower risk of redo surgery
than MIS techniques. Although
individual trials provide inconsistent
data, the pooled data in our
meta-analysis favor MD/OD. This too is
consistent with previous reviews.17,37
Strengths and Limitations
To the best of our knowledge, this is the
first multiple treatment meta-analysis for
lumbar discectomy procedures. Multiple
treatment meta-analysis is a novel
method, which helped us to detect
significant differences within individual
surgical approaches owing to subgroup
analysis. We did a comprehensive litera-
ture review and used rigorous inclusion
and exclusion criteria based on the
PRISMA guidelines.18 We employed
Cochrane Collaboration’s tool for
assessing risk of bias to evaluate the
quality of each study (Table 1).36
With this article, the first-ever effort
has been made to present an unambigu-
ous classification of each of the mini-
mally invasive approaches, something
that has been overlooked in the literature.
We scrutinized each study
401
 LITERATURE REVIEW
MOHAMMED ALI ALVI ET AL. OPERATIVE APPROACHES FOR LUMBAR DISC HERNIATION

Figure 5. (A) Forest plot comparing estimated blood loss estimated blood loss between tubular discectomy and all others
between microdiscectomy/open discectomy (MD/OD) and all and subgroup analyses.
others and subgroup analyses. (B) Forest plot comparing

comprehensively and, based on the
operative procedure explained, correctly
classified them into tubular, percuta-
neous, or percutaneous endoscopic. With
this effort, we hope that in the future,
reviewers and researchers alike will be
more careful in classifying their chosen
approach correctly.
We ultimately rely on high-quality
evidence in the form of large multi-
institutional prospective randomized
controlled trials for results. Unfortunately,
in case of surgical approaches for lumbar
disc herniation, there are only a few high-
quality trials available. We have made an
effort to do justice to each study by
presenting the most reasonable pooled
analysis, being careful to combine only
relevant studies for each outcome. None of
the studies display wide enough CIs, so we
did not feel the need for a sensitivity
analysis or a leave-one-out analysis. The
heterogeneity across each outcome and
each study was accounted for by the use of
random-effects wherever it was deemed
necessary, with the help of I2 statistics.
Even so, the results appear to be fairly
inconsistent across each study. Such
inconsistency could perhaps be contrib-
uted to intersurgeon variability or experi-
ence in minimally invasive techniques,
ultimately reflecting the advocacy, if
expressed, for the technique. Weighted
meta-regression would have been a great
method to quantify sources of heteroge-
neity and variation. However, a small
sample size makes it difficult to produce
meaningful results.
Nevertheless, our study has several
limitations as well. First, we identified
multiple studies in foreign journals for
which a translation/full text was not
available. Inclusion of these studies could
further contribute toward making the
quality of evidence higher than is pres-
ently. Also, the most well-designed study
in our reviewed suffered from low external
validity, as it only used railway workers as
patients. One of the studies was quasi-
randomized, meaning it was either
imperfectly blinded or did not employ

402 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.02.156


MOHAMMED ALI ALVI ET AL.
Figure 6. (A) Forest plot comparing total
complications between microdiscectomy/open
discectomy (MD/OD) and all others and
subgroup analyses. (B) Forest plot comparing
total complications between tubular and all
others and subgroup analyses. (C) Forest plot
comparing incidence of dural tears between
MD/OD and all others and subgroup analyses.
(D) Forest plot comparing incidence of dural
tears between tubular and all others and
subgroup analyses. (E) Forest plot comparing
WORLD NEUROSURGERY 114: 391-407, JUNE 2018
LITERATURE REVIEW
OPERATIVE APPROACHES FOR LUMBAR DISC HERNIATION
incidence of dural tears between percutaneous
endoscopic and all others and subgroup
analyses. (F) Forest plot comparing incidence
of recurrent herniation between MD/OD and all
others and subgroup analyses. (G) Forest plot
comparing incidence of recurrent herniation
between tubular discectomy and all others and
subgroup analyses. (H) Forest plot comparing
incidence of revision surgery between MD/OD
and all others and subgroup analyses.
(continues)
www.WORLDNEUROSURGERY.org 403
 LITERATURE REVIEW
MOHAMMED ALI ALVI ET AL. OPERATIVE APPROACHES FOR LUMBAR DISC HERNIATION

Figure 6. (continued)

404 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.02.156

 LITERATURE REVIEW
MOHAMMED ALI ALVI ET AL. OPERATIVE APPROACHES FOR LUMBAR DISC HERNIATION

Figure 6. (continued)

WORLD NEUROSURGERY 114: 391-407, JUNE 2018 www.WORLDNEUROSURGERY.org 405


MOHAMMED ALI ALVI ET AL.
strict randomization. Furthermore, based
on the GRADE assessment (Table 2), all
included studies had low or very-low
confidence in effect estimate. There is
also a risk of false-positive results with
multiple subgroup analyses with small
sample sizes; this could be seen with the
funnel plots in Figure 2B and D. Post hoc
analysis should be deemed exploratory
and not conclusive. Some studies
reported primary outcomes in the form
of unconventional scales that are not
uniformly practiced throughout the world.
CONCLUSIONS
To the best of our knowledge, this is the
first multiple-treatment meta-analysis of
randomized controlled clinical trials for
various operative techniques for lumbar
discectomy. We believe such studies can
help summarize the evidence for different
MIS techniques for spine surgeons so that
they may know the advantages and pitfalls
of each of the techniques.
ACKNOWLEDGMENTS
We acknowledge the efforts of Ann M.
Farrell, M.L.S., for her contribution in
review of the literature.
REFERENCES
1. Dandy WE. Loose cartilage from intervertebral
disk simulating tumor of the spinal cord. Arch
Surg. 1929;19:660-672.
2. Mixter WJ, Barr JS. Rupture of the intervertebral
disc with involvement of the spinal canal. N Engl J
Med. 1934;211:210-215.
3. Chedid KJ, Chedid MK. The “tract” of history in
the treatment of lumbar degenerative disc disease.
Neurosurg Focus. 2004;16:E7.
4. Love JG. Protruded Intervertebral Disc (Fibro-
cartilage): (Section of Orthopaedics and Section of
Neurology). Proc R Soc Med. 1939;32:1697-1721.
5. Postacchini F, Postacchini R. Operative manage-
ment of lumbar disc herniation: the evolution of
knowledge and surgical techniques in the last
century. Acta Neurochir Suppl. 2011;108:17-21.
6. Yasargil MG, Vise WM, Bader DC. Technical ad-
juncts in neurosurgery. Surg Neurol. 1977;8:331-336.
7. McCulloch JA. Focus issue on lumbar disc herni-
ation: macro- and microdiscectomy. Spine. 1996;
21:45S-56S.
8. Hijikata S, Yamagishi M, Nakayama T, Oomori K.
Percutaneous discectomy: a new treatment
406 www.SCIENCEDIRECT.com
OPERATIVE APPROACHES FOR LUMBAR DISC HERNIATION
method for lumbar disc herniation. J Toden Hosp.
1975;5:39.
9. Onik G, Helms CA, Ginsburg L, Hoaglund FT,
Morris J. Percutaneous lumbar diskectomy using a
new aspiration probe. AJR Am J Roentgenol. 1985;
144:1137-1140.
10. Welch WC, Gerszten PC. Alternative strategies for
lumbar discectomy: intradiscal electrothermy and
nucleoplasty. Neurosurg Focus. 2002;13:E7.
11. Benoist M, Deburge A, Busson J. Chemo-
nucleolysis in the treatment of sciatica caused by
herniated disk. Presse Med. 1984;13:733-736.
12. Kambin P. Arthroscopic microdiscectomy.
Arthroscopy. 1992;8:287-295.
13. Kambin P. Arthroscopic microdiscectomy: lumbar
and thoracic spine. In: White AH, ed. Spine Care.
St. Louis, MO: Mosby; 1995:1055-1066.
14. Kambin P. The role of minimally invasive surgery
in spinal disorders. Adv Op Orthop. 1995;3:147-171.
15. Smith MM, Foley KT. Microendoscopic dis-
cectomy (MED): the first 100 cases. Neurosurgery.
1998;43:702.
16. Kamper SJ, Ostelo RWJG, Rubinstein SM,
Nellensteijn JM, Peul WC, Arts MP, et al. Mini-
mally invasive surgery for lumbar disc herniation:
a systematic review and meta-analysis. Eur Spine J.
2014;23:1021-1043.
17. Rasouli MR, Rahimi-Movaghar V, Shokraneh F,
Moradi-Lakeh M, Chou R. Minimally invasive
discectomy versus microdiscectomy/open dis-
cectomy for symptomatic lumbar disc herniation.
Cochrane Database Syst Rev. 2014:CD010328.
18. Moher D, Liberati A, Tetzlaff J, Altman DG,
PRISMA Group. Preferred reporting items for
systematic reviews and meta-analyses: the
PRISMA statement. PLoS Med. 2009;6:e1000097.
19. Higgins JPT, Green S, eds. Cochrane Handbook for
Systematic Reviews of Interventions Version 5.1.0 [upda-
ted March 2011]. The Cochrane Collaboration; 2011.
Available at: http://handbook.cochrane.org.
Accessed December 10, 2016.
20. Wells G, Shea B, O’Connell D, Peterson J,
Welch V, Losos M, et al. Newcastle-Ottawa
Quality Assessment Scale, Cohort Studies. 2015-
11-19. Available at: http://www.OhriCa/programs/
clinical_epidemiology/oxford. Accessed December
10, 2016.
21. Garg B, Nagraja UB, Jayaswal A. Microendoscopic
versus open discectomy for lumbar disc hernia-
tion: a prospective randomised study. J Orthop
Surg. 2011;19:30-34.
22. Teli M, Lovi A, Brayda-Bruno M, Zagra A,
Corriero A, Giudici F, et al. Higher risk of dural
tears and recurrent herniation with lumbar micro-
endoscopic discectomy. Eur Spine J. 2010;19:
443-450.
23. Ruetten S, Komp M, Merk H, Godolias G. Full-
endoscopic interlaminar and transforaminal lum-
bar discectomy versus conventional microsurgical
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.02.156
LITERATURE REVIEW
technique: a prospective, randomized, controlled
study. Spine. 2008;33:931-939.
24. Pan L, Zhang P, Yin Q. Comparison of tissue
damages caused by endoscopic lumbar dis-
cectomy and traditional lumbar discectomy: a
randomised controlled trial. Int J Surg. 2014;12:
534-537.
25. Shin DA, Kim KN, Shin HC, Yoon DH. The effi-
cacy of microendoscopic discectomy in reducing
iatrogenic muscle injury. J Neurosurg Spine. 2008;8:
39-43.
26. Righesso O, Falavigna A, Avanzi O. Comparison
of open discectomy with microendoscopic dis-
cectomy in lumbar disc herniations: results of a
randomized controlled trial. Neurosurgery. 2007;61:
545-549 [discussion: 549].
27. Huang T-J, Hsu RW-W, Li Y-Y, Cheng C-C. Less
systemic cytokine response in patients following
microendoscopic versus open lumbar discectomy.
J Orthop Res. 2005;23:406-411.
28. Hermantin FU, Peters T, Quartararo L, Kambin P.
A prospective, randomized study comparing the
results of open discectomy with those of video-
assisted arthroscopic microdiscectomy. J Bone
Joint Surg Am. 1999;81:958-965.
29. Mayer HM, Brock M. Percutaneous endoscopic
discectomy: surgical technique and preliminary
results compared to microsurgical discectomy.
J Neurosurg. 1993;78:216-225.
30. Belykh E, Giers MB, Preul MC, Theodore N,
Byvaltsev V. Prospective comparison of microsur-
gical, tubular-based endoscopic, and endoscopi-
cally assisted diskectomies: clinical effectiveness
and complications in railway workers. World
Neurosurg. 2016;90:273-280.
31. Abrishamkar S, Kouchakzadeh M, Mirhosseini A,
Tabesh H, Rezvani M, Moayednia A, et al. Com-
parison of open surgical discectomy versus
plasma-laser nucleoplasty in patients with single
lumbar disc herniation. J Res Med Sci. 2015;20:
1133-1137.
32. Ryang Y-M, Oertel MF, Mayfrank L, Gilsbach JM,
Rohde V. Standard open microdiscectomy versus
minimal access trocar microdiscectomy: results of
a prospective randomized study. Neurosurgery.
2008;62:174-181 [discussion: 181-182].
33. Chatterjee S, Foy PM, Findlay GF. Report of a
controlled clinical trial comparing automated
percutaneous lumbar discectomy and micro-
discectomy in the treatment of contained lumbar
disc herniation. Spine. 1995;20:734-738.
34. Arts M, Brand R, van der Kallen B, Lycklama à
Nijeholt G, Peul W. Does minimally invasive
lumbar disc surgery result in less muscle injury
than conventional surgery? A randomized
controlled trial. Eur Spine J. 2011;20:51-57.
35. Corniola MV, Stienen MN, Tessitore E, Schaller K,
Gautschi OP. Minimally invasive spine surgery:
past and present. Rev Med Suisse. 2015;11:
2186-2189.
 LITERATURE REVIEW
MOHAMMED ALI ALVI ET AL. OPERATIVE APPROACHES FOR LUMBAR DISC HERNIATION

36. Higgins JP, Altman DG, Gøtzsche PC, Jüni P,
Moher D, Oxman AD. The Cochrane Collab-
oration’s tool for assessing risk of bias in
randomised trials. BMJ. 2011;343:d5928.
37. Ruan W, Feng F, Liu Z, Xie J, Cai L, Ping A.
Comparison of percutaneous endoscopic lumbar
discectomy versus open lumbar microdiscectomy
for lumbar disc herniation: a meta-analysis. Int J
Surg. 2016;31:86-92.
Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Received 3 January 2018; accepted 26 February 2018
Citation: World Neurosurg. (2018) 114:391-407.
https://doi.org/10.1016/j.wneu.2018.02.156
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2018 Elsevier Inc. All
rights reserved.

WORLD NEUROSURGERY 114: 391-407, JUNE 2018 www.WORLDNEUROSURGERY.org 407

 LITERATURE REVIEW
MOHAMMED ALI ALVI ET AL. OPERATIVE APPROACHES FOR LUMBAR DISC HERNIATION

SUPPLEMENTARY MATERIAL 1 Other Non-Indexed Citations and Ovid Reviews - Cochrane Database of
SEARCH STRATEGY: OVID MEDLINE(R) 1946 to Present, EBM Systematic Reviews 2005 to August 17,
Database(s): Embase 1988 to 2016 Week Reviews - Cochrane Central Register of 2016
34, Ovid MEDLINE(R) In-Process & Controlled Trials July 2016, EBM

Search Strategy

# Searches Results

1 exp Lumbar Vertebrae/ 59,990

2 ((lumbal or lumbar) and (vertebra* or vertebrae or spine or spinal or disc* or disk* 190,792
or "transverse process*")).mp.
3 1 or 2 190,792
4 exp Intervertebral Disc/su [Surgery] 3150
5 exp Diskectomy/ 12,263
6 (((disk or disks or disc or discs) adj3 (surg* or operat* or resect* or repair* or 23,351
reconstruct*)) or APLD or discectom* or diskectom* or microdiscectom* or
microdiskectom* or nucleotom*).mp.
7 4 or 5 or 6 25,028
8 (laser or lasers or Chemonucleos*).mp. 511,512
9 7 not 8 24,259
10 3 and 9 12,699
11 limit 10 to (editorial or erratum or letter or note or addresses or autobiography or 541
bibliography or biography or blogs or comment or dictionary or directory or
interactive tutorial or interview or lectures or legal cases or legislation or news or
newspaper article or overall or patient education handout or periodical index or
portraits or published erratum or video-audio media or webcasts) [Limit not valid in
Embase,Ovid MEDLINE(R),Ovid MEDLINE(R) In-Process,CCTR,CDSR; records were
retained]
12 from 11 keep 1-528 528
13 10 not 12 12,171
14 exp controlled study/ 5,197,584
15 exp Randomized Controlled Trial/ 828,226
16 exp triple blind procedure/ 135
17 exp Double-Blind Method/ 376,885
18 exp Single-Blind Method/ 60,199
19 exp latin square design/ 331
20 exp Placebos/ 303,369
21 exp Placebo Effect/ 9106
22 ((control* adj3 study) or (control* adj3 trial) or (randomized adj3 study) or 6,770,755
(randomized adj3 trial) or (randomised adj3 study) or (randomised adj3 trial) or
"pragmatic clinical trial" or (doubl* adj blind*) or (doubl* adj mask*) or (singl* adj
blind*) or (singl* adj mask*) or (tripl* adj blind*) or (tripl* adj mask*) or (trebl* adj
blind*) or (trebl* adj mask*) or "latin square" or placebo* or nocebo*).mp,pt.
23 or/14-22 6,770,809
24 23 and random*.mp,pt. 1,824,692
25 13 and 24 1543

Continues

407.E1 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.02.156

 LITERATURE REVIEW
MOHAMMED ALI ALVI ET AL. OPERATIVE APPROACHES FOR LUMBAR DISC HERNIATION

Continued

# Searches Results
26 exp meta analysis/ 186,117
27 exp Meta-Analysis as Topic/ 44,000
28 exp "systematic review"/ 112,361
29 exp "Review"/ 4,109,268
30 ((meta adj analys*) or (systematic* adj3 review*) or review*).mp,pt. 6,223,597
31 or/26-30 6,227,151
32 25 not 31 1345
33 remove duplicates from 32 711
34 13 and 31 2605
35 remove duplicates from 34 1778

SCOPUS 5 DOCTYPE(le) OR DOCTYPE(ed) OR 8 TITLE-ABS-KEY(random*)

1 TITLE-ABS-KEY(((lumbal or lumbar)
and (vertebra* or vertebrae or spine or
spinal or disc* or disk* or "transverse
process*")))
2 TITLE-ABS-KEY(((disk or disks or disc
or discs) W/3 (surg* or operat* or
resect* or repair* or reconstruct*)) OR
APLD OR discectom* OR diskectom*
OR microdiscectom* OR micro-
diskectom* OR nucleotom*)
3 TITLE-ABS-KEY(laser or lasers
Chemonucleos*)
4 (1 and 2) and not 3
DOCTYPE(bk) OR DOCTYPE(er) OR
9 6 and 7 and 8
DOCTYPE(no) OR DOCTYPE(sh)
10 TITLE-ABS-KEY((meta W/1 analys*) or
6 4 and not 5
(systematic* W/3 review*) or review*)
7 TITLE-ABS-KEY((control* W/3 study)
11 9 and not 10
or (control* W/3 trial) or (randomized
W/3 study) or (randomized W/3 trial) or 12 PMID(0*) OR PMID(1*) OR PMID(2*)
(randomised W/3 study) or (rando- OR PMID(3*) OR PMID(4*) OR
mised W/3 trial) or "pragmatic clinical PMID(5*) OR PMID(6*) OR PMID(7*)
trial" or (doubl* W/1 blind*) or (doubl* OR PMID(8*) OR PMID(9*)
W/1 mask*) or (singl* W/1 blind*) or 13 11 and not 12
(singl* W/1 mask*) or (tripl* W/1
or 14 6 and 10
blind*) or (tripl* W/1 mask*) or (trebl*
W/1 blind*) or (trebl* W/1 mask*) or 15 14 and not 12
"latin square" or placebo* or nocebo*)

WORLD NEUROSURGERY 114: 391-407, JUNE 2018 www.WORLDNEUROSURGERY.org 407.E2