Comparative efficacy and safety of three surgical procedures for the treatment of lumbar disc herniation: a Bayesian-based network analysis.

purposeExisting studies have suggested that the efficacy and safety of tubular microdiscectomy (TMD) and percutaneous transforaminal endoscopic discectomy (TED) for lumbar disc herniation (LDH) are similar to those of open microdiscectomy (OMD). However, there are no head-to-head randomized controlled trials (RCTs) making indirect or integrated comparisons of the efficacy and safety of TMD and TED for LDH. A network meta-analysis (NMA) of RCTs was used to compare the clinical efficacy and safety of OMD, TMD and TED for LDH in this research.

methodsWe systematically searched the Cochrane Library, PubMed, and Embase databases from their inceptions through March 2023 for eligible literature. The following search terms were used: "transforaminal endoscopic discectomy," "microdiscectomy," "endoscopic," "minimally invasive," "tubular microdiscectomy," "spinal disease," and "randomized clinical trial". The primary outcomes were the Oswestry disability index (ODI) score and the visual analog scale (VAS) score for leg pain, complications, and reoperation. Direct comparison meta-analyses and NMA were carried out.

resultsEight RCTs (1391 patients) met the inclusion criteria. Pairwise meta-analysis showed that compared to OMD, TED has advantages in terms of VAS score (SMD=-1.10 95% CI - 1.85 to -0.34, P = 0.005) and ODI score (SMD=-5.17 95% CI - 8.04 to -2.31, P = 0.004). In contrast, the comparative analysis revealed no statistically significant differences between TMD and OMD across all outcome measures. By comparing TED to OMD and TMD to OMD, it was found that there was no significant difference in the complication and reoperation rates. NMA indicated that there was no significant difference in any of the outcomes between TED and TMD. Trend analyses of rank probabilities showed the cumulative probabilities of the most effective treatments, as measured by primary outcomes (VAS score, ODI score, reoperation and complication rates), were TED (95%, 77%, 23%, 58%), TMD (4%, 22%, 54%, 36%), and OMD (1%, 1%, 23%, 6%).

conclusionFor LDH, TED outperformed OMD in clinical efficacy, while TMD matched OMD outcomes. All modalities showed similar complication/reoperation rates. Probabilistic analyses revealed TED as preferable for younger patients (enhanced pain control, shorter stays), whereas TMD better suited elderly comorbid patients for reoperation risk mitigation.