Percutaneous Transforaminal Endoscopic Discectomy and Fenestration Discectomy to Treat Posterior Ring Apophyseal Fractures: A Retrospective Cohort Study

Abstract

Objective: To compare the efficacy and safety of percutaneous transforaminal endoscopic discectomy (PTED) and fenestration discectomy (FD) for posterior ring apophyseal fractures (PRAF).

Methods: This study was a retrospective cohort control study. A total of 96 patients with lumbar PRAF who underwent surgical treatment at the Henan Provincial People's Hospital of Henan University from September 2013 to December 2017 were retrospectively examined, of which 51 were treated by PTED and 45 by FD. The average age of those in the PTED group was 28.24 years, including 38 males and 13 females. The average age of those in the FD group was 28.07 years, with 33 males and 12 females. Operation time, total blood loss, hospitalization days, preoperative and postoperative visual analog scale (VAS), and Oswestry disability index (ODI) scores were evaluated. Modified MacNab criteria were used to evaluate the clinical effect at the last follow-up.

Results: Both operations were successful and no serious complications occurred. All patients were followed up for 12-30 (average 16.7 ± 3.2) months, and no patients were lost to follow-up. No statistically significant difference was found in the mean age and gender between the PTED group and the FD group (P < 0.05). Operation time, total blood loss, and length of hospital stay were significantly lower in the PTED group (87.65 ± 13.15 min, 12.78 ± 4.95 mL, and 6.80 ± 1.67 days, respectively) than in the FD group (114.11 ± 14.39 min, 30.89 ± 7.09 mL, and 11.71 ± 1.98 days, respectively) (P < 0.05). The VAS and ODI scores of the two groups at postoperative day 1 (PTED: 3.82 ± 0.97, 37.73% ± 3.72%; FD: 3.62 ± 1.09, 36.62% ± 3.05%), and at 3 months (PTED: 2.90 ± 1.08, 26.02% ± 2.90%; FD: 3.07 ± 0.99, 27.16% ± 4.02%), 6 months (PTED: 2.31 ± 0.88, 22.53% ± 2.67%; FD: 2.36 ± 0.77, 21.18% ± 3.35%), and the last follow-up (PTED: 1.90 ± 0.83, 19.88% ± 3.01%; FD: 1.89 ± 0.86, 18.22% ± 3.03%) were significantly different from the preoperative scores (PTED: 6.53 ± 1.00, 55.24% ± 4.54%; FD: 6.78 ± 1.31, 53.56% ± 5.73%) (P < 0.05). The VAS and ODI scores at 3 months postoperatively, 6 months postoperatively, and the last follow up were not significantly different between the two groups (P > 0.05). In the PTED group, 2 patients developed a transient nerve stimulation symptom within 1 day after surgery and 1 patient had recurrence at 3 months after surgery. In the FD group, 2 patients had severe dural ruptures due to adhesion during surgery, 1 patient developed infection complications, and 2 patients relapsed at 2 and 3 months after surgery. At the last follow-up, the modified MacNab criteria for clinical effect were 93.3% and 94.1% in the FD and PTED groups, respectively.

Conclusion: While PTED has the same efficacy as FD for treating PRAF, it is associated with shorter operation time, less trauma, and quicker recovery.

Keywords: Discectomy; Fenestration; Lumbar; Percutaneous transforaminal endoscopic; Posterior ring apophyseal fracture.

Figure 1

A 33‐year‐old male patient was hospitalized for pain and numbness of the left lower extremity for 6 months. (A & B) Preoperative CT images; his diagnosis was L₅S₁ posterior ring apophyseal fracture. (C & D) Postoperative CT images. After percutaneous transforaminal endoscopic discectomy, most of the bones were removed, and a small amount of bone remained. Soft tissue was removed and symptoms of compression were relieved.

Figure 2

A 27‐year‐old male patient was hospitalized for low back pain and right lower extremity pain for 4 months. (A & B) Preoperative CT images; his diagnosis was L_4–5 posterior ring apophyseal fracture. (C & D) Postoperative CT images. After FD, the bone was removed, and the compression was released.

Figure 3

The course of the pain in both groups, which was rated using the mean visual analog scale. FD, fenestration discectomy; PTED, percutaneous transforaminal endoscopic discectomy.

Figure 4

The course of the lumbar function in both groups, which was rated using the Oswestry disability index. FD, fenestration discectomy; PTED, percutaneous transforaminal endoscopic discectomy.