Comparison of Outcomes of Percutaneous Endoscopic Lumbar ...download.xuebalib.com/xuebalib.com.19484.pdf · symptomatic lumbar disc diseases1,6-9; however, open surgery results in

Original Article

Comparison of Outcomes of Percutaneous Endoscopic Lumbar Discectomy

and Open Lumbar Microdiscectomy for Young Adults: A Retrospective MatchedCohort Study

Sang-Soak Ahn1, Sang-Hyeon Kim2, Dong-Won Kim2, Byung-Hun Lee3

-OBJECTIVE: There have been only a few studies onsurgical treatment of lumbar disc herniation (LDH) in youngadults. In addition, previous studies do not provide detailedinformation on the surgical outcomes for young adults withLDH. The purpose of this study was to compare theoutcome of transforaminal percutaneous endoscopic lum-bar discectomy (PELD) and open lumbar microdiscectomyfor active, young adults (age 20e25 years).

-METHODS: We performed retrospective chart and radi-ography. The patients were divided into 2 groups accordingto the surgical methods. Group A included the patients whounderwent transforaminal PELD, and Group B included thepatients who underwent open lumbar microdiscectomy forLDH at L4/5. After we matched for several factors, 32 youngpatients in group A and 34 young patients in group B wereanalyzed. We compared the outcomes between the 2groups in terms of clinical, radiologic, perioperative out-comes, and surgery-related complications.

-RESULTS: The clinical results for leg pain and radiologicresults for decompression were the same in both groups.Most of complications in the PELD group occurred in theearly phase. The recurrence rate and operation failure ratewas no difference between the groups. The PELD broughtsignificant advantages in the following areas: back pain,operation time, blood loss, hospital stay, and return-to-work.

Key words- Diskectomy- Percutaneous- Endoscopy- Intervertebral disc displacement- Young adult

Abbreviations and AcronymsDSCSA: Dural sac cross-sectional areaLDH: Lumbar disc herniationMRI: Magnetic resonance imagingODI: Oswestry Disability IndexOLM: Open lumbar microdiscectomyPELD: Percutaneous endoscopic lumbar diskectomyPLL: Posterior longitudinal ligamentSF-12: 12-item short form health survey

250 www.SCIENCEDIRECT.com WORLD NEU

-CONCLUSIONS: Although a learning curve is needed inorder to become familiar with PELD, PELD seemed to be agood choice for disc herniation in the lumbar spine foractive, young adults.

INTRODUCTION

umbar disc herniation (LDH) is a relatively common causeof sciatica in young adults.1-5 Most young adults with LDH
Lcan be managed properly with conservative treatment;
however, a small number of patients do not respond effectively toconservative treatment and eventually require surgical treatment.There are 2 main surgical options: open lumbar microdiscectomy(OLM) and percutaneous endoscopic lumbar discectomy (PELD).OLM has been considered to be the gold standard procedure forsymptomatic lumbar disc diseases1,6-9; however, open surgeryresults in muscle damage, the removal of the yellow ligament, andnerve retraction. This can cause instability and scarring of theepidural space, which becomes clinically symptomatic in 10% ormore of patients.6,7,9,10 PELD has been performed as an alternativeto classic open discectomy with comparable results. There arepotential downsides of the tranforaminal PELD, such as transientparesthesias, a larger annular defect, and difficulties accessingL5/S1 in patients with a prominent iliac crest. In addition, thelearning curve is perceived to be steep. However, it has severaladvantages over open discectomy, including (1) the ability to beperformed under local anesthesia; (2) minimal postoperative pain

VAS: Visual analog scale

From the 1Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam SeveranceSpine Hospital, Yonsei University College of Medicine, Seoul; 2Department of Radiology,Dong-A University Medical Center, Busan; and 3Department of Neurosurgery, The ArmedForces Capital Hospital, Seongnam, Korea

To whom correspondence should be addressed: Sang-Soak Ahn, M.D.[E-mail: [email protected]]

Citation: World Neurosurg. (2016) 86:250-258.http://dx.doi.org/10.1016/j.wneu.2015.09.047

Journal homepage: www.WORLDNEUROSURGERY.org

Available online: www.sciencedirect.com

1878-8750/$ - see front matter ª 2016 Elsevier Inc. All rights reserved.

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ORIGINAL ARTICLE

SANG-SOAK AHN ET AL. PELD VERSUS OLM FOR YOUNG ADULTS

and preservation of the normal para-spinal muscles; and (3) aminimization of the risk of postoperative epidural scar formationand instability.4,11-18 A consensus on the preferred surgical methodin young patients has not been established, however, and therehave only been a few studies in which the authors examined thesurgical treatment of LDH in young adults.1,2,4,5

We conducted this study to compare the clinical, radiologic,and perioperative outcomes of transforaminal PELD and OLM foryoung adults (age 20e25 years) with LDH, as well as the surgery-related complications. To the best of our knowledge, this is thefirst study to compare the outcomes of PELD and OLM in youngadults by the use of a retrospective matched cohort design.

MATERIALS AND METHODS

Study DesignThis study was carried out after we obtained approval from theinstitutional review board (The Armed Forces Capital Hospital[AFMC-15041-IRB-15-057]). Between May 2012 and January 2014,178 consecutive patients with LDH who underwent surgical treat-ment were considered for this study. The inclusion criteria were asfollows: (1) a soft LDH within the spinal canal in L4�5 (including

Figure 1. Flowchart depicting patient selection. OLM, lumbar mdiscectomy.

WORLD NEUROSURGERY 86: 250-258, FEBRUARY 2016

the sequestering of material located cranially below the lower edgeof the cranial pedicle or caudally not over the middle of the caudalpedicle), with lumbar spine radiographs, computed tomography,and magnetic resonance image (MRI) corresponding to the clinicalsymptoms; (2) age between 20 and 25 years; (3) nonresponse to atleast 8 weeks of conservative treatment, including medication,physical therapy, and injections; (4) a surgical procedure performedby the designated spine surgeon (S.S.A.); and (5) follow-up of atleast 1 year. Those who met any of the following criteria wereexcluded: (1) lateral recess stenosis, hard disc herniation, foraminaland extraforaminal disc herniations, and spinal instability; (2)follow-up of less than 1 year; and (3) an inability to accuratelycomplete the pre- and postoperative questionnaires. Ninety-sevenpatients were excluded because of these criteria.The patients were divided into 2 groups according to the sur-

gical methods. Group A included the patients who underwentPELD for disc herniation, and Group B included those who un-derwent OLM. After we matched for tobacco smoking and bodymass index between the 2 groups, 32 patients in group A and 34patients in group B were analyzed (Figure 1). All of these patientswere Korean military serviceman at the time of their operations.Before surgery, all patients were informed of the details of the

icrodiscectomy; PELD, percutaneous endoscopic lumbar

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ORIGINAL ARTICLE


surgery, including the anesthesia process, potentialcomplications, and benefits of the procedures. One spinesurgeon with 4 years of surgical experience was involved in thestudy. The selection of the surgical method was based on thissurgeon’s recommendation as well as patient preference.

Clinical AssessmentClinical and demographic data were recorded prospectively. Thepatients completed a questionnaire consisting of a 10-pointvisual analog scale (VAS) for low back pain and leg pain pre-operatively and at each follow-up visit. The patients alsocompleted the Oswestry Disability Index (ODI) and a 12-itemshort form health survey (SF-12) for their quality of life preop-eratively and at each follow-up visit. The physical componentsummary and mental component summary of the SF-12 wererecorded separately. Follow-up visits occurred at 6 and 12months after surgery. Patients were not allowed to review theirprevious results. The operation time, blood loss, hospital stay,return-to-work time, complication rate, failure rate, and 12-month reherniation rate were evaluated to assess the outcomesof the procedures.

Radiologic AssessmentAll patients underwent MRI preoperatively and at 12 months aftersurgery. The change in the dural sac cross-sectional area (DSCSA)between the preoperative and the postoperative MRI was evaluatedto demonstrate the extent of decompression. This space wasdrawn by an imaginary area at the narrowest lesion on the T2-weighted axial MRI (Figure 2). The MRI scans were performedusing a 1.5-T MRI system (Signa Excite scanner, General ElectricCompany, Milwaukee, Wisconsin, USA) with a slice thickness of 5mm. To evaluate the radiologic parameters, two radiologists(S.H.K. and D.W.K.) independently measured the preoperativeand postoperative parameters using a picture archiving commu-nication system feature (Marosis 5.0 PACS viewer, Marotech,Seoul, Korea).

Figure 2. Dural sac cross-sectional area between the preopera(MRI). The space was drawn by an imaginary area at the narrowpicture archiving communication system.


Surgical ProcedureIn group A, we used the “in-and-out-and-in” technique. All op-erations were performed under local anesthesia after sedation ofthe patient with the intramuscular administration of midazolam(0.1 mg/kg) in the prone position. Before surgery, we checked thelateral view of the C-arm image and determined the entry point,which was between the tip of the spinous process and the spi-nolaminar junction on the lateral view. The entry point was usually10�15 cm from the midline. The entry point was projected to have20�25 degrees of access (from the coronal plane) for L4�5. An 18-gauge spinal needle was introduced under the biplanar guidanceof fluoroscopy. The final target point of the needle was the medialpedicular line on the anteroposterior view and the posteriorvertebral line on the lateral view.At this point, epidurography was performed with contrast me-

dium and local anesthesia was carried out using 1% lidocaine.After the insertion of the needle into the disc, evocative chro-modiscography was performed with contrast medium and indigo-carmine. A guide wire was then inserted through the needle, andthe needle was removed. A linear skin incision about 8 mm longwas made at the entry point, and an obturator (YESS system;Richard Wolf, Knittlingen, Germany) was gently introduced by atwisting maneuver. A bevel-ended working sheath was insertedinto the disc space along the obturator, and then the obturator wasremoved. After we placed the endoscope within the workingsheath, the disc fragment at the base of the herniated mass wasremoved with a high-voltage bipolar probe manufactured by Ell-man (Ellman Innovation, Hicksville, New York, USA) and pituitaryforceps. After the removal of the central disc fragment, theworking sheath was moved back to the epidural space and theposterior longitudinal ligament (PLL) was removed in the half-and-half view (Figure 3). After removal of the PLL, while weconfirmed the pulsation of the dura with direct visualization, theposterolateral target fragment was removed by introducing theworking sheath from the lateral to the medial area. After allprocedures were complete, the endoscope was removed, and

tive and the postoperative magnetic resonance imagingest lesion on the T2-weighted axial MRI by the use of a


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Figure 3. Intraoperative endoscopic view in transforaminal approach with the posterior longitudinal ligament (A), whichis removed by cutter (B). D, herniated disc stained by indigocarmine; F, epidural fat; P, posterior longitudinal ligament).

Table 1. Demographic Data

Characteristics Group A Group B P Value

Number of patients 32 34

Mean age, year* 22.41 � 1.68 22.18 � 1.51 0.56Sex, male/female 32/0 34/0 1.00

Height, cm* 173.09 � 5.90 172.56 � 5.89 0.71Weight, kg* 66.53 � 6.60 67.03 � 6.24 0.75BMI, kg/m2* 22.16 � 1.22 22.46 � 0.90 0.26Smoking, %y 10 (31.2) 10 (29.4) 0.87Follow-up, mo* 13.69 � 1.26 13.41 � 1.02 0.33BMI, body mass index.*Student t test.yc2 test.

ORIGINAL ARTICLE


a sterile dressing was performed with a one-point suture. Thepatients were able to communicate with the surgeon during theentire procedure.In group B, the procedure was performed under general anes-

thesia in the prone position on a Wilson frame. A 3-cm posteriormidline skin incision was made over the appropriate disc space. Alimited laminotomy was performed using a high-speed drill. Bythe use of a small annulotomy if needed, the disc fragment wasremoved in the conventional manner under microscopic view. Theforamen was then routinely probed for residual fragments or bonylesions. After confirming the decompression of the nerve root, theclosure was performed in the conventional manner.8

StatisticsStatistical analyses were performed using SPSS version 20.0 (SPSSInc., Chicago, Illinois, USA). The mean values � standard de-viations or the medians with the interquartile ranges are shown.Student t tests were conducted to confirm intergroup differencesin cases with normal distributions. Mann-Whitney U tests wereused to compare variables between two groups with non-normaldistributions. For the categorical variables, c2 tests and Fischerexact tests were performed between 2 independent groups. AllP-values less than .05 were considered statistically significant.

RESULTS

DemographicsWe reviewed 32 patients in group A (PELD) and 34 patients ingroup B (OLM) who met the inclusion and exclusion criteria.Patient demographics including the follow-up period were notsignificantly different between the 2 groups (Table 1).

Clinical OutcomesPreoperatively, the back and leg VAS scores were 4.41 � 0.98 and7.53 � 0.92, respectively, in group A and, 4.74 � 1.08 and 7.50 �0.93, respectively, in group B. These results revealed no significantdifferences. After surgery, the VAS scores for the back and leg


decreased significantly in both groups. At 12 months after surgery,the back and leg VAS scores were 2.50 � 0.62 and 2.06 � 0.84,respectively, in group A and 2.91 � 0.67 and 2.32 � 1.01,respectively, in group B. There were significant differences be-tween the groups for back VAS score at 6 months and 12 monthsafter surgery (P < 0.001, P ¼ 0.012, respectively). However, therewas no significant difference between the groups for leg VAS scoreafter surgery (Figure 4).The mean ODI scores significantly improved from baseline at

the final follow-up in both groups (Figure 5). As depicted inFigure 5, there was a significant difference in ODI scoresbetween the groups at 6 months after surgery (P ¼ 0.004). Themean physical component summary score and mentalcomponent summary score in the SF-12 improved at the finalfollow-up time as compared to the baseline in both groups(Figure 6). As depicted in Figure 6, there was a significant

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Figure 4. Clinical outcomes using visual analog scale (VAS) scores. There were significant differences between thegroups for the back VAS at 6 and 12 months after surgery (yP < 0.013, z0.012, respectively).

ORIGINAL ARTICLE


difference in mental parameters between the groups at 6 monthsafter surgery (P ¼ 0.002) (Table 2).

Radiologic OutcomesThe preoperative DSCSA was 58.60 � 23.07 mm2 in group A and57.30 � 22.13 mm2 in group B. The postoperative DSCSA was 75.25� 23.10 mm2 in group A and 75.83 � 22.00 mm2 in group B. Theexpansion in DSCSA between the preoperative and the post-operative MRI was 16.65 � 6.58 mm2 in group A and 18.53 � 6.19mm2 in group B. However, there was no significant differencebetween the groups (P ¼ 0.092) (Table 3, Figure 7).

Perioperative OutcomesThe mean operating time was significantly shorter in group A(48.66 � 6.45 minutes) as compared with group B (53.71 � 8.49minutes) (P ¼ 0.009). There was no measurable blood loss ingroup A; the mean intraoperative blood loss was 41.26 � 31.88 mL

Figure 5. Clinical outcomes using Oswestry Disability Index (ODI) scores.*Statistically significant differences between scores in each follow-uptime (P < 0.05). Preop, preoperative.


(15e167 mL) in group B. However, both groups had negligibleblood loss with no clinical significance. The mean hospital staywas significantly shorter in group A (7.50 � 2.63 days) ascompared with group B (15.65 � 4.80 days) (P < 0.001). The meanreturn-to-work time was significantly shorter in group A (13.94 �3.72 days) as compared with group B (29.26 � 5.80 days)(P < 0.001) (Table 4).

ComplicationsComplications occurred in 4 patients (12.5%) in group A and 4patients (11.8%) in group B. Four patients complained of dyses-thesia on the posterolateral thigh, which spontaneously improved2�3 days after surgery (2 cases in group A and 2 cases in group B).A dural tear occurred in 1 patient in group B, which was suc-cessfully managed with direct repair. One patient with the longestoperative time in group A complained of headache during surgery,especially near the end of the procedure, which spontaneouslyimproved after bed rest for 1 day. One patient presented with asymptomatic pseudocyst 2 months after PELD, which slowlyimproved after an epidural block. Postoperative epidural hema-toma occurred in one patient in group B, which was successfullyremoved with evacuation. There were no major complicationssuch as neurovascular injury, retroperitoneal hematoma, andsurgical-site infections in either group, and there were no signif-icant differences in the complication rate between the 2 groups(Table 4).

Operation Failures and RecurrencesIncomplete removal of the target fragment occurred in 2 patientsin group A, which we considered surgical failures. Because thesepatients complained of leg pain after surgery, we performed a MRIin the immediate postoperative period and detected the residualfragments. However, no patients underwent reoperations due topatient preference and were instead managed with conservativetreatment. There was no significant difference in the failure ratebetween the 2 groups (P ¼ 0.231). Reherniation at 12 monthsoccurred in one patient in group A (3.1%) and one patient in groupB (2.9%). The patient in the PELD group with reherniationoccurred at 6 months after surgery and was managed with



Figure 6. Clinical outcomes using 12-item short form health survey (SF-12) scores. *Statistically significant differencesbetween scores in each follow-up time (P < 0.05). PCS, physical component summary; MCS, mental componentsummary.

Table 2. Clinical Outcomes According to the Parameters

Parameters Group A (n [ 32) Group B (n [ 34) P Value

VAS (back)

Preop 4.41 � 0.98 4.74 � 1.08 0.2016 months 2.66 � 0.70 3.53 � 0.71

Figure 7. Expansion of the dural sac cross-sectional area (DSCSA). yTherewas no significant difference between the groups (P ¼ 0.092).

ORIGINAL ARTICLE


in the ODI score was considered to reflect clinical improvement,as proposed by the Food and Drug Administration.7 ODI scorereductions were similar to those reported previously by Ruettenet al.18 using the PELD and OLM techniques. However, both theODI and mental SF-12 scores tended to worsen after 6 monthspostoperatively in the OLM group. There are several reasons forthe worse outcomes in the OLM group 6 months after surgerycompared with the PELD group: (1) OLM requires further muscledissection and the removal of posterior structures such as thelamina, yellow ligament, and facet joint, which might affectpostoperative back pain as well as physical and mental statuses;and (2) all patients were active young men who returned to a

Table 4. Summary of Perioperative Outcomes, Complications,Failure, and Recurrence Rate

Group A (n [ 32) Group B (n [ 34) P Value

Op time, min* 48.66 � 6.45 53.71 � 8.49 0.009EBL, mL Not measureable 41.26 � 31.88Hospital stay, daysy 7.50 � 2.63 15.65 � 4.80 0.05Op, operation; EBL, estimated blood loss.*Student t test.yMann-Whitney U test.zFisher’s exact test.


military environment after surgery, with intense physical trainingand duties.It is difficult to predict the outcomes for patients in both groups

in the next 10�20 years. However, we would expect lower rates ofdegeneration and recurrence in the PELD group given its relativelyminimally invasive approach. Studies with longer follow-up pe-riods are needed to address this question.

Comparison of Radiologic OutcomesMany previous studies have measured the DSCSA to evaluate theseverity of spinal stenosis.20-22 However, the relationship betweenthe DSCSA and clinical symptoms has been uncertain, with poorcorrelation in most published studies.21,22 In addition, to the bestof our knowledge, there has been no study that has used theDSCSA to evaluate the extent of decompression in LDH. Becausethere is as of yet no alternative measurement technique to assessthe extent of decompression, we used the DSCSA to measure theexpansion ratio of the dural sac. Despite improvements in theDSCSA after surgery in both groups, there were no statisticallysignificant differences between the groups. We did not investigatethe correlation of the DSCSA to clinical outcomes because we onlywanted to assess the amount of decompression between the 2groups. To compare the extent of decompression in LDH as wellas its clinical correlations, advancements in measurement tech-niques are necessary.

Comparison of Perioperative OutcomesThe mean operative time in the PELD group was significantlyshorter than that of the OLM group. Blood loss was not meas-ureable in the PELD group and was negligible in the OLM group.Despite the fact that the mean operative time in our study waslonger than previously reported times, the intergroup results weresimilar.18

Comparison of ComplicationsAlthough the published complication rate for PELD was lowerthan that for OLM,13,18,23 there were 4 complications after PELD(12.5%) and 4 complications after OLM (11.8%) in the presentstudy. Like any other technique, PELD has its own learning curve.Most of the complications in the PELD group, such as transientdysesthesia and intraprocedure headache, occurred in the earlyphases of the study. Sairyo et al.24 reported that an elevation inintracranial pressure may occur if the irrigation pressure is toohigh or if the endoscopic maneuvers take too long. In thepresent case, one patient complained of headache duringsurgery and also had the longest operative time in our study’searly phases.Choi et al.11 reported that the working sheath may compress the

exiting root during surgery, and thus a prolonged operation timemay contribute to nerve irritation. In the present study, weexperienced2 such cases, both of which also occurred in theearly phases. In addition, there was 1 case of a symptomaticpostdiscectomy pseudocyst after PELD. Kang and Park25

reported that symptomatic postdiscectomy pseudocyst wasdetected within 2 months postoperatively in about 1% of cases.The authors suggested that there was no difference in treatmentoutcomes between the surgical and conservative management ofsymptomatic pseudocysts. The pseudocyst in the present study



ORIGINAL ARTICLE


was detected at 2 months postoperatively, and slowly improvedafter epidural injection. Although the complication rates in bothgroups were greater than those described in previous studies,there were no major complications.13,18 These results showedthat with proper patient selection, PELD is a safe and effectiveprocedure after overcoming its learning curve.

Comparison of Hospital Stay and Return to WorkThe length of the hospital stay and return-to-work time are veryimportant parameters in the assessment of a patient’s quality oflife. Although the relationship between these measures and apatient’s overall health is uncertain, these factors may be related toimprovements in patient outcome and productivity by reducingthe duration of their disability.6 In the present study, similar to theresults of previous studies,13,17-19 the mean hospital stay in thePELD group was shorter than that of the OLM group. However,the mean hospital stays for the patients in both the PELD andOLM groups were longer than those reported in previousstudies.13,18 This may have occurred because all patients wereactive young men who were required to maintain weight standardsand physical readiness even though they had recently undergonesurgery, and therefore, the hospital stay in the present study mayhave included some period of time even after the relief fromsymptoms. In the present study, similar to the results of previousstudies, the mean return-to-work time for the PELD group wasshorter than that for the OLM group.13,17-19

Comparison of Operation Failures and RecurrencesAs previously described, incomplete removal of the target frag-ment occurred in 2 patients in the PELD group, which we regardedas surgical failures. All of these cases occurred in the early phasesof our study and may be the result of technical limitations. Nopatients underwent reoperation due to patient preference andwere instead managed with conservative treatment. We hypothe-sized that the recurrence rate in young patients would be greaterthan those reported in previous studies; however, 12-month discreherniation was only observed in 1 case (3.1%) in the PELD groupand 1 case (2.9%) in the OLM group, a rate comparable with thosereported in a previous study (5.7% and 6.6% for PELD and OLM,respectively).18 In previous studies, a large annular defect inpatients in the OLM group resulted in significantly greater ratesof recurrence than smaller or covered defects.18,26,27 However, inthe present study, sequestrotomy with partial extirpation wasperformed in OLM cases involving small or covered annular de-fects. Therefore, we could not examine the relationship between


the sizes of the annular defects and the clinical outcomes. Leeet al.4 hypothesized that their study’s relatively high reherniationrate may be attributable to limited target fragmentectomy in thePELD group. In the present study, we could not only remove thetarget fragment but also the central fragment using an “in-and-out-and-in” technique. Through this technique, we could checkon the target fragment while re-introducing a working channelfrom the lateral to medial area after removal of the PLL.

LimitationsIt is important to note that the present study has several limita-tions. First, it was a retrospective matched cohort study with asmall sample size (32 and 34 patients for the PELD and OLMgroups, respectively), short follow-up periods (1 year), limitedoperative levels (L4�5), and limited indications (excluding harddiscs and foraminal/extraforaminal disc herniations). To investi-gate the efficacy of the surgical methods, prospective randomizednoninferiority or superiority studies are necessary. Second, thestudy participants were limited to men who were recruited from anarmed forces hospital. Because this study was conducted in alimited population, statistical analysis was difficult because of anon-normal distribution, and this study’s conclusions might notbe valid for general populations. However, because this studyincluded a homogeneous population of young patients from anarmed forces hospital, we could reduce selection bias and per-formance bias. In addition, because we could match several fac-tors (sex, age, height, weight, body mass index, and tobaccosmoking) between the 2 groups, we could also reduce confound-ing bias. However, prospective double-arm parallel studies withlonger follow-up times and larger sample sizes are necessary toprovide more useful information on the outcomes of PELD andOLM for LDH.

CONCLUSION

In our opinion, the use of PELD in young adults has several ad-vantages, including: (1) a simpler surgical procedure due to theavailability of local anesthesia, a short operative time, and a shorthospital stay; (2) more efficacy for back pain and quality of life ascompared to OLM, especially in active patients; and (3) a relativelylow recurrence rate, even in patients undergoing intense physicalactivity. Although surgeons need to overcome a learning curve tobecome familiar with PELD, the procedure seems to be a goodchoice for the treatment of LDH in young and active patients.

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Conflict of interest statement: The authors declare that thearticle content was composed in the absence of anycommercial or financial relationships that could be construedas a potential conflict of interest.

Received 2 July 2015; accepted 15 September 2015

Citation: World Neurosurg. (2016) 86:250-258.http://dx.doi.org/10.1016/j.wneu.2015.09.047

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Comparison of Outcomes of Percutaneous Endoscopic Lumbar Discectomy and Open Lumbar Microdiscectomy for Young Adults: A Ret ...IntroductionMaterials and MethodsStudy DesignClinical AssessmentRadiologic AssessmentSurgical ProcedureStatistics

ResultsDemographicsClinical OutcomesRadiologic OutcomesPerioperative OutcomesComplicationsOperation Failures and Recurrences

DiscussionComparison of Clinical OutcomesComparison of Radiologic OutcomesComparison of Perioperative OutcomesComparison of ComplicationsComparison of Hospital Stay and Return to WorkComparison of Operation Failures and RecurrencesLimitations

ConclusionReferences

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