# Comparison of Clinical Efficacy and Recovery Effect between Lateral and Posterior Foraminoscopy and PELD in LDH Patients

Authors: Zhimin Zhang; Yaning Zhang; Chunxia Huang; Jianzhong Huo
Journal: Contrast Media & Molecular Imaging
 (2022)

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## Abstract

In order to analyze the clinical efficacy and recovery of lumbar disc herniation (LDH) treated by lateral and posterior foraminoscopy and posterior approach foraminoscopy (PELD), the comparison of clinical efficacy and recovery effect between lateral and posterior foraminoscopy and PELD in LDH patients was conducted. A total of 96 LDH patients admitted to our hospital from July 2020 to July 2021 were selected, and the lateral and posterior foraminoscopy group and PELD group were, respectively, established according to different surgical intervention methods. The lateral posterior foraminoscopy group is treated with lateral posterior foraminoscopy intervention, and the PELD group is treated with posterior foraminoscopy intervention. The intraoperative and postoperative indicators of the two groups were observed, and the pain improvement, lumbar function, clinical efficacy, and incidence of adverse complications were compared between the two groups before and 3 months after surgery. The Spearman correlation coefficient is used to analyze the correlation between visual analogue scale (VAS) score, lumbar function (ODI) score, and the incidence of complications. For patients with LDH in implementing lientang road intervertebral foramen mirror, the clinical efficacy of the intervertebral foramen to a rear mirror was more apparent. It demonstrates that the treatment can reduce intraoperative blood loss, shorten hospitalization time, improve lumbar vertebral function, and reduce a patient’s risk of complications.


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## Body

## 1. Introduction

Lumbar disc herniation (LDH) is a kind of orthopedic disease frequently occurring in the middle-aged and elderly population. Relevant clinical research data indicate that the pathogenesis of LDH is mainly due to the aging of the patient, which makes the lumbar disc more fragile, or the external forces of the patient lead to the damage of the annulus fibroids. The damaged annulus fibrosus of the nucleus pulposus and its surroundings were detached from the site of the injury [1, 2]. As the peripheral disc is almost surrounded by spinal nerve roots and spinal cord, the affected nucleus pulposus will be squeezed after shedding, thus bringing adverse symptoms to patients [3]. According to the study of LDH, nearly 20% of patients need intensive surgical intervention to improve clinical efficacy, but trauma patients often use traditional fenestration. It not only affects the rapid recovery of lumbar function, but also increases the economic burden of hospitalized patients [4, 5]. With the pursuit of minimally invasive surgery in clinical practice and the continuous improvement of relevant technical level, minimally invasive surgery is increasingly widely applied in LDH patients, aiming to reduce the trauma to patients during surgery and promote rapid postoperative recovery [6]. It should be noted that, under the influence of the pathogenesis of LDH, general minimally invasive surgery cannot clearly observe and effectively remove the nucleus pulposus tissue during the operation, while lateral and posterior foraminoscopy and posterior discscopy can solve this problem [7].In order to further clarify the clinical efficacy of different approaches for patients with LDH and the recovery effects of various functions for patients, the lateral and posterior foraminoscopy and posterior discscopy in patients with LDH are applied in this study, and comparative analysis of intraoperative, postoperative, and clinical symptoms of patients is conducted.The remainder of this paper is organized as follows. Section2 discusses related work, followed by the data and method in Section 3. The results and analysis are discussed in Section 4. Section 5 concludes the paper with a summary.


## 2. Related Work

Degenerative changes are the basic factor of LDH, and repeated external forces caused by long-term overwork tend to cause slight damage to intervertebral discs and aggravate the degree of degeneration [8, 9]. At present, absolute bed rest, physiotherapy, massage, and other conservative treatments can relieve the symptoms of LDH to a certain extent, but there are still many patients with ineffective treatments who require surgery [10]. Previous lumbar surgery focuses on a thorough removal of nucleus pulposus tissue. However, with the continuous development of minimally invasive surgery technology, treatment ideas are constantly updated, and the guiding ideology for the treatment of lumbar disc herniation does not deliberately pursue the number of nucleus pulposus extirpated [11, 12]. It should be satisfied with the requirement of the degeneration of nucleus pulposus removal. The compression of nerve roots can be relieved to improve the clinical symptoms of patients [13].The posterior approach is the most commonly used approach to foraminoscopy and can effectively establish a minimally invasive working channel to complete the operation of nucleus pulposus removal [14]. However, posterior approach foraminoscopy often requires nerve root pulling, local bone removal, free ligamentum flavum, and excessive removal of intervertebral disc tissue, which is easy to cause nerve root injury and scar adhesion and is not conducive to patient rehabilitation [15–17]. With the development of minimally invasive endoscopic technology, the lateral and posterior approach has been gradually applied in foraminoscopy, which has the advantages of less trauma, fewer complications, quick recovery, and good efficacy [18–20]. The results showed that compared with the posterior approach group, the amount of intraoperative blood loss and length of hospital stay in the posterior approach group were significantly decreased (P<0.05), and the incidence of postoperative complications was significantly decreased (P<0.05). At the same time, the VAS score and ODI score of the two groups were significantly improved 3 months after operation compared with that before operation, indicating that the two approaches of foraminoscopy have a definite effect on LDH treatment. The reason may be that both the posterior approach and the lateral posterior approach can directly reach the affected intervertebral space through the foraminoscope, and the effective endoscope-assisted removal of the nucleus pith can effectively restore the lumbar function of LDH patients. Among the total postoperative response rate, VAS and ODI scores showed that LDH patients had more obvious clinical improvement effects. In addition, the results of this study showed that the number of intraoperative fluoroscopy and operation time in the lateral posterior approach group significantly increased, suggesting that compared with the posterior approach, the operation of lumbar foraminoscopy in the treatment of LDH is more complex, requiring long-term clinical operation experience and good three-dimensional positioning ability.Besides, I have a good command of LDH anatomical characteristics and endoscopic operation techniques. However, we believe that the number of intraoperative fluoroscopy and operation time should be effectively reduced after the operator gradually passes the learning curve of the lateral posterior approach.


## 3. Data and Method

### 3.1. General Information

A total of 96 LDH patients admitted to our hospital from July 2020 to July 2021 were selected, and the lateral and posterior foraminoscopy group and PELD group were, respectively, established according to different surgical intervention methods, with 48 patients in each group. In the lateral and posterior foraminoscopy groups, there were 26 males and 22 females, aged 34–75 years, with a mean of 51.26 ± 5.42 years and a mean of 7.68 ± 2.57 years, with a course of 2–12 years. There were 29 males and 19 females in the PELD group, aged from 32 to 76 years, with an average of 52.04 ± 5.51 years, and the course of disease ranged from 3 to 12 years, with an average of 8.03 ± 2.65 years. There were no significant statistical differences in clinical baseline data, including gender, age, disease course, and other relevant data (allP>0.05), which confirmed that the comparison between groups was scientific and reasonable.Inclusion criteria include the following aspects: (1) the clinical symptoms and related diagnostic results of patients showed that LDH was confirmed; (2) all patients underwent first surgery; (3) complete clinicopathological data of patients; and (4) patients with high clinical compliance can cooperate with relevant investigation work of this study until the end of the study.Methylene blue includes as follows: (1) tumor and related tumor lesions were seen in the patient’s spine; (2) patients with spinal tuberculosis-related diseases; (3) patients with functional disorders related to the immune system and blood system; (4) patients with severe osteoporosis; (5) complicated with serious organic dysfunction of the liver and kidney; and (6) patients with a history of mental illness or clinical signs of disturbance of consciousness.


### 3.2. The Proposed Method

All patients in the PELD group received posterior foraminoscopy intervention. Specific surgical procedures were summarized and guided to keep patients in a prone position. During the operation, the angle of the operating bed was adjusted to ensure that the patients’ waists were in a moderate flexion state, and foreshadowing was slightly suspended. At the same time, the needle was applied to the intervertebral disc for surgical site orientation, to clear lesions after vertebral body clearance to its position as a center, and to apply a scalpel to make a long, approximately 8 mm incision. With the help of the working cannula, a Wolf endoscope of 4.2 mm was inserted into the vertebroscopy system and connected to the TV screen. The herniated disc tissue was resected, the herniated nucleus pulposus was removed, and then the nerve root of the patient was released. The nerve root tension within the range of activity of 1 cm was checked, and the straight leg elevation test of the affected limb was performed, and the operation was ended after a negative reaction was confirmed.The lateral posterior foraminoscopy group received the lateral posterior foraminoscopy. The C-arm X-ray machine was used to assist the fluoroscopy of the affected part of the patient and determine the target intervertebral disc lesions. Marks were made at the anterolateral position, the spinous process line, and the body surface line of the target intervertebral disc (if the lumbar 5-sac1 intervertebral disc herniation is present, marks should be made at the iliac crest line of the affected side). The puncture angle was selected and maintained at 30∼40°. Intervertebral disc discography was performed with 0.1% methylene blue after successful puncture of an intervertebral disc lesion. Lumbar 4-5 disc herniation was 10∼12 cm away from the midline, and lumbar 5-s1 disc herniation was 12∼14 cm away. The clinician will remove blood clots, bone fragments, and ligamentum flavum in the surgical field, identify the posterior longitudinal ligament, perform an endoscopic cutting operation under rinse solution, and remove the blue herniated disc tissue of the patient. After the patient’s nucleus pulposus residue and surrounding normal tissue damage were confirmed, routine postoperative management was performed.


### 3.3. Observation Indicators

The observation indicators include the following:(1)
The number of intraoperative fluoroscopies, operation time, intraoperative blood loss, hospitalization days, and other indicators were compared.(2)
The pain improvement before and 3 months after the operation was compared. Clinical pain was assessed by a visual analog scale (VAS) score before and 3 months after the surgery, and the VAS score increased with the aggravation of pain.(3)
The lumbar function of the two groups was compared before and 3 months after the operation. The Oswestry Disability Index Questionnaire (ODI) was used to assess the lumbar function of LDH patients, and the ODI score decreased with the improvement of the recovery of lumbar function.(4)
The clinical efficacy of the two groups was compared. The total effective rate can be defined as follows: the total effective rate = (number of effective cases + number of effective cases)/total number of cases × 100%.(5)
The incidence of adverse complications was compared.(6)
The correlation between VAS score, ODI score, and the occurrence of complications in LDH patients was analyzed.


### 3.4. Statistical Processing

SPSS 26.0 software was used for statistical analysis of the data involved in this study. The part of the measurement data in this study was represented by mean ± standard deviation (x¯±s) after confirming normal distribution, and the data differences between groups were tested by a t-test. In this study, the part of the counting data was represented by (n, %), and the data differences between groups were effectively analyzed by the x2 test. The Spearman correlation coefficient was used to analyze the correlation between postoperative pain degree and lumbar spine function of LDH patients and their complications, and P<0.05 proved that the differences were statistically significant.


## 3.1. General Information

A total of 96 LDH patients admitted to our hospital from July 2020 to July 2021 were selected, and the lateral and posterior foraminoscopy group and PELD group were, respectively, established according to different surgical intervention methods, with 48 patients in each group. In the lateral and posterior foraminoscopy groups, there were 26 males and 22 females, aged 34–75 years, with a mean of 51.26 ± 5.42 years and a mean of 7.68 ± 2.57 years, with a course of 2–12 years. There were 29 males and 19 females in the PELD group, aged from 32 to 76 years, with an average of 52.04 ± 5.51 years, and the course of disease ranged from 3 to 12 years, with an average of 8.03 ± 2.65 years. There were no significant statistical differences in clinical baseline data, including gender, age, disease course, and other relevant data (allP>0.05), which confirmed that the comparison between groups was scientific and reasonable.Inclusion criteria include the following aspects: (1) the clinical symptoms and related diagnostic results of patients showed that LDH was confirmed; (2) all patients underwent first surgery; (3) complete clinicopathological data of patients; and (4) patients with high clinical compliance can cooperate with relevant investigation work of this study until the end of the study.Methylene blue includes as follows: (1) tumor and related tumor lesions were seen in the patient’s spine; (2) patients with spinal tuberculosis-related diseases; (3) patients with functional disorders related to the immune system and blood system; (4) patients with severe osteoporosis; (5) complicated with serious organic dysfunction of the liver and kidney; and (6) patients with a history of mental illness or clinical signs of disturbance of consciousness.


## 3.2. The Proposed Method

All patients in the PELD group received posterior foraminoscopy intervention. Specific surgical procedures were summarized and guided to keep patients in a prone position. During the operation, the angle of the operating bed was adjusted to ensure that the patients’ waists were in a moderate flexion state, and foreshadowing was slightly suspended. At the same time, the needle was applied to the intervertebral disc for surgical site orientation, to clear lesions after vertebral body clearance to its position as a center, and to apply a scalpel to make a long, approximately 8 mm incision. With the help of the working cannula, a Wolf endoscope of 4.2 mm was inserted into the vertebroscopy system and connected to the TV screen. The herniated disc tissue was resected, the herniated nucleus pulposus was removed, and then the nerve root of the patient was released. The nerve root tension within the range of activity of 1 cm was checked, and the straight leg elevation test of the affected limb was performed, and the operation was ended after a negative reaction was confirmed.The lateral posterior foraminoscopy group received the lateral posterior foraminoscopy. The C-arm X-ray machine was used to assist the fluoroscopy of the affected part of the patient and determine the target intervertebral disc lesions. Marks were made at the anterolateral position, the spinous process line, and the body surface line of the target intervertebral disc (if the lumbar 5-sac1 intervertebral disc herniation is present, marks should be made at the iliac crest line of the affected side). The puncture angle was selected and maintained at 30∼40°. Intervertebral disc discography was performed with 0.1% methylene blue after successful puncture of an intervertebral disc lesion. Lumbar 4-5 disc herniation was 10∼12 cm away from the midline, and lumbar 5-s1 disc herniation was 12∼14 cm away. The clinician will remove blood clots, bone fragments, and ligamentum flavum in the surgical field, identify the posterior longitudinal ligament, perform an endoscopic cutting operation under rinse solution, and remove the blue herniated disc tissue of the patient. After the patient’s nucleus pulposus residue and surrounding normal tissue damage were confirmed, routine postoperative management was performed.


## 3.3. Observation Indicators

The observation indicators include the following:(1)
The number of intraoperative fluoroscopies, operation time, intraoperative blood loss, hospitalization days, and other indicators were compared.(2)
The pain improvement before and 3 months after the operation was compared. Clinical pain was assessed by a visual analog scale (VAS) score before and 3 months after the surgery, and the VAS score increased with the aggravation of pain.(3)
The lumbar function of the two groups was compared before and 3 months after the operation. The Oswestry Disability Index Questionnaire (ODI) was used to assess the lumbar function of LDH patients, and the ODI score decreased with the improvement of the recovery of lumbar function.(4)
The clinical efficacy of the two groups was compared. The total effective rate can be defined as follows: the total effective rate = (number of effective cases + number of effective cases)/total number of cases × 100%.(5)
The incidence of adverse complications was compared.(6)
The correlation between VAS score, ODI score, and the occurrence of complications in LDH patients was analyzed.


## 3.4. Statistical Processing

SPSS 26.0 software was used for statistical analysis of the data involved in this study. The part of the measurement data in this study was represented by mean ± standard deviation (x¯±s) after confirming normal distribution, and the data differences between groups were tested by a t-test. In this study, the part of the counting data was represented by (n, %), and the data differences between groups were effectively analyzed by the x2 test. The Spearman correlation coefficient was used to analyze the correlation between postoperative pain degree and lumbar spine function of LDH patients and their complications, and P<0.05 proved that the differences were statistically significant.


## 4. Results and Analysis

### 4.1. Comparison of Intraoperative and Postoperative Indicators

The number of intraoperative fluoroscopy and operation time in the lateral and posterior foraminoscopy groups increased significantly compared to the PELD group, while the amount of intraoperative blood loss and length of hospital stay in the lateral and posterior foraminoscopy group decreased significantly compared to the PELD group (allP<0.05), as shown in Table 1 and Figure 1.Table 1
Comparison of intraoperative and postoperative indicators (x¯±s).
GroupIntraoperative fluoroscopy times (times)The operation time (min)Intraoperative blood loss (mL)The length of time (d)Lateral and posterior foraminoscopy group (n = 48)14.17 ± 1.6570.45 ± 7.3827.13 ± 4.826.21 ± 2.56PELD group (n = 48)8.24 ± 1.1361.27 ± 6.6453.65 ± 8.1710.33 ± 3.24T20.5446.407−19.369−6.913P<0.001<0.001<0.001<0.001Figure 1
Comparison of lumbar MRI before and after surgery.


### 4.2. Incidence of Postoperative Complications

The number of postoperative adverse complications such as incision infection, cerebrospinal fluid leakage, intraspinal hematoma, and limb numbness in the lateral and posterior foraminoscopy group was lower than that in the PELD group, and the total incidence of complications decreased significantly compared to that in the PELD group (P<0.05), as shown in Table 2.Table 2
Comparison of postoperative complications (n, %).
GroupInfection of incisionCerebrospinal fluid leakageIntraspinal hematomaNumbnessTotal complication rateLateral and posterior foraminoscopy group (n = 48)1 (2.08)1 (2.08)0 (0.00)1 (2.08)3 (6.25)PELD group (n = 48)4 (8.33)3 (6.25)2 (4.17)3 (6.25)12 (25.00)x2————6.400P————0.011


### 4.3. Pain Improvement

There was no significant difference in VAS scores before surgery (P>0.05). VAS scores decreased significantly 3 months after surgery, and VAS scores of the lateral and posterior foraminoscopy groups decreased significantly compared to the PELD group (all P<0.05), as shown in Table 3. In Table 3, ∗ represents a comparison with before surgery, P<0.05.Table 3
Comparison of VAS scores before and 3 months after the surgery (scores,x¯±s).
GroupBefore the operation3 months after surgeryLateral and posterior foraminoscopy group (n = 48)6.76 ± 0.682.15 ± 0.46∗PELD group (n = 48)6.64 ± 0.613.47 ± 0.55∗T0.910−12.755P0.365<0.001


### 4.4. Lumbar Function

There was no significant difference in ODI scores before surgery (P>0.05), ODI scores in both groups showed a significant decreasing trend 3 months after surgery, and ODI scores in the lateral and posterior foraminoscopy group decreased significantly compared to the PELD group (all P<0.05), as shown in Table 4. In Table 4, the symptom ∗ represents a comparison with before surgery, P<0.05.Table 4
Comparison of ODI scores before and 3 months after the surgery (scores,x¯±s).
GroupBefore the operation3 months after surgeryLateral and posterior foraminoscopy group (n = 48)55.17 ± 6.0823.47 ± 1.25∗PELD group (n = 48)54.46 ± 5.8928.15 ± 1.86∗T0.581−14.469P0.563<0.001


### 4.5. Postoperative Clinical Efficacy

The total clinical response rate of the lateral and posterior foraminoscopy group increased significantly compared to the PELD group (P<0.05), as shown in Table 5.Table 5
Comparison of postoperative clinical efficacy (n, %).
GroupObvious effectEffectiveInvalidTotal clinical response rateGroup29 (60.42)14 (29.17)5 (10.42)43 (89.58)Lateral and posterior foraminoscopy group (n = 48)21 (43.75)10 (20.83)13 (27.08)31 (64.58)x2————P————


### 4.6. Correlation between VAS Score, ODI Score, and the Occurrence of Complications

The Spearman correlation coefficient analysis showed that VAS score and ODI score were significantly negatively correlated with the occurrence of complications (P<0.05), as shown in Table 6.Table 6
Correlation analysis of VAS score, ODI score, and patient complications.
ItemComplicationsrsPVAS score−0.714<0.001ODI score0.689<0.001


## 4.1. Comparison of Intraoperative and Postoperative Indicators

The number of intraoperative fluoroscopy and operation time in the lateral and posterior foraminoscopy groups increased significantly compared to the PELD group, while the amount of intraoperative blood loss and length of hospital stay in the lateral and posterior foraminoscopy group decreased significantly compared to the PELD group (allP<0.05), as shown in Table 1 and Figure 1.Table 1
Comparison of intraoperative and postoperative indicators (x¯±s).
GroupIntraoperative fluoroscopy times (times)The operation time (min)Intraoperative blood loss (mL)The length of time (d)Lateral and posterior foraminoscopy group (n = 48)14.17 ± 1.6570.45 ± 7.3827.13 ± 4.826.21 ± 2.56PELD group (n = 48)8.24 ± 1.1361.27 ± 6.6453.65 ± 8.1710.33 ± 3.24T20.5446.407−19.369−6.913P<0.001<0.001<0.001<0.001Figure 1
Comparison of lumbar MRI before and after surgery.


## 4.2. Incidence of Postoperative Complications

The number of postoperative adverse complications such as incision infection, cerebrospinal fluid leakage, intraspinal hematoma, and limb numbness in the lateral and posterior foraminoscopy group was lower than that in the PELD group, and the total incidence of complications decreased significantly compared to that in the PELD group (P<0.05), as shown in Table 2.Table 2
Comparison of postoperative complications (n, %).
GroupInfection of incisionCerebrospinal fluid leakageIntraspinal hematomaNumbnessTotal complication rateLateral and posterior foraminoscopy group (n = 48)1 (2.08)1 (2.08)0 (0.00)1 (2.08)3 (6.25)PELD group (n = 48)4 (8.33)3 (6.25)2 (4.17)3 (6.25)12 (25.00)x2————6.400P————0.011


## 4.3. Pain Improvement

There was no significant difference in VAS scores before surgery (P>0.05). VAS scores decreased significantly 3 months after surgery, and VAS scores of the lateral and posterior foraminoscopy groups decreased significantly compared to the PELD group (all P<0.05), as shown in Table 3. In Table 3, ∗ represents a comparison with before surgery, P<0.05.Table 3
Comparison of VAS scores before and 3 months after the surgery (scores,x¯±s).
GroupBefore the operation3 months after surgeryLateral and posterior foraminoscopy group (n = 48)6.76 ± 0.682.15 ± 0.46∗PELD group (n = 48)6.64 ± 0.613.47 ± 0.55∗T0.910−12.755P0.365<0.001


## 4.4. Lumbar Function

There was no significant difference in ODI scores before surgery (P>0.05), ODI scores in both groups showed a significant decreasing trend 3 months after surgery, and ODI scores in the lateral and posterior foraminoscopy group decreased significantly compared to the PELD group (all P<0.05), as shown in Table 4. In Table 4, the symptom ∗ represents a comparison with before surgery, P<0.05.Table 4
Comparison of ODI scores before and 3 months after the surgery (scores,x¯±s).
GroupBefore the operation3 months after surgeryLateral and posterior foraminoscopy group (n = 48)55.17 ± 6.0823.47 ± 1.25∗PELD group (n = 48)54.46 ± 5.8928.15 ± 1.86∗T0.581−14.469P0.563<0.001


## 4.5. Postoperative Clinical Efficacy

The total clinical response rate of the lateral and posterior foraminoscopy group increased significantly compared to the PELD group (P<0.05), as shown in Table 5.Table 5
Comparison of postoperative clinical efficacy (n, %).
GroupObvious effectEffectiveInvalidTotal clinical response rateGroup29 (60.42)14 (29.17)5 (10.42)43 (89.58)Lateral and posterior foraminoscopy group (n = 48)21 (43.75)10 (20.83)13 (27.08)31 (64.58)x2————P————


## 4.6. Correlation between VAS Score, ODI Score, and the Occurrence of Complications

The Spearman correlation coefficient analysis showed that VAS score and ODI score were significantly negatively correlated with the occurrence of complications (P<0.05), as shown in Table 6.Table 6
Correlation analysis of VAS score, ODI score, and patient complications.
ItemComplicationsrsPVAS score−0.714<0.001ODI score0.689<0.001


## 5. Conclusions

In this study, a total of 96 LDH patients were selected to analyze the clinical efficacy and recovery of lumbar disc herniation (LDH) treated by lateral and posterior foraminoscopy and posterior approach foraminoscopy (PELD). The results show that postoperative pain and ODI scores are closely related to postoperative complications. It indicates that we should pay attention to their rapid rehabilitation and pain management as well as timely surgical intervention for patients with LDH. That is conducive improving the prognosis of patients and improving the clinical efficacy. Compared with the posterior approach, lateral foraminoscopy has more accurate efficacy in the treatment of LDH and has the advantages of high safety and fast recovery, which makes it worthy of clinical application.



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