ENDOSCOPY IN LUMBAR ADJACENT LEVEL DISEASE - SYSTEMATIC REVIEW AND META-ANALYSISABSTRACT
Introduction: Degenerative disease is a complex condition to treat, given the multiple possibilities for treatment and the fact that the population with the highest prevalence of the condition tends to be older and more frail. Endoscopic techniques are increasingly used to treat this group of pathologies to minimize the risks and improve patient recovery.
Methods: Systematic review and meta-analysis, with the keywords used in the search engines: “adjacent segment disease” and “endoscopic surgery”.
Results: 9 articles, totaling ten entries, were included in the quantitative analysis. The studies, in general, were of low quality. The number of complications per 1000 patients was 94. The average ODI value at the last follow-up point was 12 points, with back VAS averaging 2.17 and leg VAS averaging 1.91.
Conclusion: Endoscopic techniques potentially improve patients’ clinical outcomes and have a low complication rate. However, higher-quality studies are needed to visualize the real impact of the technique on the treatment of adjacent-level pathologies. Level of Evidence I; Systematic Revision and Metanalysis.
Keywords:
Chronic Disease; Review; Quality of Life; Endoscopy; Middle Aged
RESUMO
Introdução: A doença degenerativa é uma doença complexa de ser tratada, tendo em vista as múltiplas possibilidades de tratamento e que a população com maior prevalência da doença tende a ser mais idosa e mais frágil. Visando minimizar os riscos e melhorar a recuperação dos pacientes, cada vez mais as técnicas de endoscopia vêm sendo utilizadas para o tratamento deste grupo de doenças.
Métodos: Revisão sistemática e meta-análises, com as seguintes palavras-chave utilizadas nos mecanismos de busca, “adjacente segment disease” e “endoscopic surgery”.
Resultados: 9 artigos, totalizando 10 entradas, foram incluídos na análise quantitativa. Os estudos em geral apresentaram uma qualidade baixa. A ocorrência de complicações por 1000 pacientes foi apontada como de 94. Já o valor médio de ODI no último ponto de acompanhamento foi de 12 pontos, com o VAS costas apresentando média de 2,17 e o VAS pernas apresentando média de 1,91.
Conclusão: As técnicas endoscópicas aparentam ter potencial para promover melhora nos desfechos clínicos dos pacientes, além de apresentarem baixa taxa de complicações. No entanto, estudos com maior qualidade são necessários para visualizarmos o real impacto da técnica sobre o tratamento das doenças do nível adjacente. Nível de Evidência I; Revisão Sistemática e Metanálise.
Descritores:
Doença Crônica; Revisão; Qualidade de Vida; Endoscopia; Pessoa de Meia-Idade
RESUMEN
Introducción: La enfermedad degenerativa es una patología compleja de tratar, dadas las múltiples posibilidades de tratamiento y el hecho de que la población con mayor prevalencia de la patología suele ser de edad avanzada y más frágil. Con el fin de minimizar los riesgos y mejorar la recuperación de los pacientes, cada vez se utilizan más las técnicas endoscópicas para tratar este grupo de patologías.
Métodos: Revisión sistemática y metaanálisis, con las siguientes palabras clave utilizadas en los buscadores: “adjacent segment disease” y “endoscopic surgery”.
Resultados: En el análisis cuantitativo se incluyeron 9 artículos, con un total de 10 entradas. En general, los estudios eran de baja calidad. El número de complicaciones por 1000 pacientes fue de 94. El valor medio del ODI en el último punto de seguimiento fue de 12 puntos, con una media de 2,17 en la VAS de la espalda y de 1,91 en la VAS de las piernas.
Conclusión: Las técnicas endoscópicas parecen tener potencial para mejorar los resultados clínicos de los pacientes y presentan una baja tasa de complicaciones. Sin embargo, se necesitan estudios de mayor calidad para visualizar el impacto real de la técnica en el tratamiento de las patologías de nivel adyacente. Nivel de Evidencia I; Revisión Sistemática y Metaanálisis.
Descriptores:
Enfermedad Crónica; Revisión; Calidad de Vida; Endoscopía; Persona de Mediana Edad
INTRODUCTION
The treatment of adjacent-level disease is complex, as the surgeon must deal with a previous construction, which can influence the local anatomy and the patient’s ability to recruit compensatory mechanisms. This disease can be classified according to the symptoms and the treatment required. Fusion is necessary to stabilize the segment in cases involving instability and stenosis or just instability. In cases without instability, isolated decompressions are often enough to relieve the patient’s symptoms.1
With the increase in the number of surgeries performed on elderly and frail populations and the consequent increase in the prevalence of adjacent-level disease, there is an increasing search for less invasive and more effective techniques for treating this disease.2
Among minimally invasive techniques, endoscopy has established itself as a valuable technique in the treatment of various spinal conditions due to its versatility and minimally invasive profile. It allows complex diseases to be treated even in the most fragile populations.3,4
Despite being established for treating various spine diseases, the literature has not yet highlighted endoscopic techniques for treating diseases of the adjacent level of the spine.3,4
Therefore, this study aims to carry out a systematic review and meta-analysis of the literature to identify the effect of endoscopy on clinical outcomes and the occurrence of complications when applied to the treatment of adjacent-level diseases.
METHODS
Search and retrieval strategy
Electronic databases, including PubMed, Google Scholar, Ovid and VHL, were systematically reviewed using the following search strategy: Search: ((“adjacent”[All Fields] OR “adjacently”[All Fields] OR “adjacents”[All Fields]) AND (“segment”[All Fields] OR “segment s”[All Fields] OR “segmental”[All Fields] OR “segmentally” [All Fields] OR “segmentals”[All Fields] OR “segmentation”[All Fields] OR “segmentational”[All Fields] OR “segmentations”[All Fields] OR “segmented”[All Fields] OR “segmenter”[All Fields] OR “segmenters”[All Fields] OR “segmenting”[All Fields] OR “segments”[All Fields]) AND (“disease”[MeSH Terms] OR “disease”[All Fields] OR “diseases”[All Fields] OR “disease s” [All Fields] OR “diseased”[All Fields]) AND (“endoscopy”[MeSH Terms] OR “endoscopy”[All Fields] OR (“endoscopic”[All Fields] AND “surgery”[All Fields]) OR “endoscopic surgery”[All Fields])) AND (review[Filter]). Filters: from NA to 2023”. Only original articles in English or Portuguese were included in the review.
Selection and Inclusion Criteria
The authors selected the studies in two stages. The first consisted of a brief analysis of the title/abstract, in which the authors looked for evidence to decide whether or not the work should proceed to the next stage. At this stage, the articles that raised doubts about whether they met the inclusion criteria were forwarded to the second stage.
In the second stage, the authors checked the full text of the remaining articles. At this point, the inclusion criteria were as follows: (I) Patients with adjacent level disease; (II) Endoscopic lumbar surgery techniques; (III) The article is a randomized clinical trial, a prospective, or a retrospective study. The exclusion criteria were: (I) Studies that did not detail any of the outcomes studied; (II) Studies that could not be found in full text.
Data Extraction
Continuous variables will only be included if the article provides the standard deviation or other information that allows each group’s standard deviation to be calculated. Studies presenting two or more subgroups will be divided by the number of subgroups presented, adding the “-x” next to the article ID (Ex: A, A-1).
Quality assessment
To assess the articles’ quality, the authors used the Cochrane Foundation’s RoB-Risk2 tool for randomized clinical trials and the Newcastle Ottawa Scale (NOS) for prospective and retrospective cohort studies.5,6
Sensitivity Analysis
The sensitivity analysis used the “leave-one-out” method, where an article is removed from the outcome-specific meta-analysis.
Statistical Analysis
Meta-analysis studies were carried out to identify the proportion of complications after lumbar endoscopy. The results were presented on the scale of events/1000 cases. The results for single-arm continuous variables are presented as standardized mean differences (MD). In contrast, the continuous variables of meta-analysis of means are presented as mean, and proportion data are presented as proportion of occurrences in the total population of the analysis. Heterogeneity between studies was assessed using Cochran’s Q statistical test, and heterogeneity between included studies was assessed using the chi-squared test, with p < 0.05 indicating heterogeneity. In the presence of heterogeneity, the random effects model is used, and in other cases, the common effects model. In addition, the “leave-one-out” method was used to assess the impact of each study on the effect of the meta-analysis, whereby studies that caused a change in the effect of more than 5% when removed were presented as a result of the meta-analysis without excluding these studies.
RESULTS
Fifty-nine articles were identified through the search engine, and one additional article was found by searching for references. Of these, 47 were excluded, and 12 went on to the full-text analysis stage. Three of these 12 articles were excluded, and nine were included in the qualitative and quantitative analysis. (Figure 1)
Flow of inclusion of studies, as proposed by the PRISMA method (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).
Of the nine articles included, one divided the endoscopic techniques into two groups, counting them twice. The most commonly addressed level was L3-L4, followed by L4-L5 (Table 1). Of the ten entries included, one used only interlaminar techniques, one used both interlaminar and transforaminal techniques, while the other seven entries used only transforaminal techniques. (Table 1)
As for the quality of the studies evaluated, all 10 were retrospective studies. On average, the retrospective studies had a median score of 3 points, with a minimum score of 3 points and a maximum score of 5 points. (Table 2)
Of the variables studied, ODI and back VAS had the most studies and patients. (Table 3)
Eight studies were included in the analysis of the occurrence of complications. The heterogeneity between the entries was considered to be high (I2 = 57%) and significant, so the random effects method was chosen. The proportion of complications per 1000 patients was 106.2 (95% Confidence Interval = 42.0 - 189.83). (Figure 2)
Forest-Plot refers to the meta-analysis of proportions of complications after endoscopic techniques.
8 studies were included in the analysis of ODI scores at the last follow-up point. The heterogeneity between the studies was considered to be high (I2 = 79%), which is why the random effects method was chosen. Thus, the average ODI score at the last follow-up point was 14.7 (95% Confidence Interval = 12.14 - 17.31). (Figure 3)
As for back VAS scores at the last follow-up point, 9 studies were included. The heterogeneity between the studies was considered to be high (I2 = 94%), which is why the random effects method was chosen. Thus, the average VAS leg score at the last follow-up point was 2.17 (95% Confidence Interval = 1.66 - 2.68). (Figure 4)
Finally, when analyzing VAS scores in the legs at the last follow-up point, 5 studies were included. The heterogeneity between the studies was considered to be high (I2 = 79%), which is why the random effects method was chosen. Thus, the average VAS leg score at the last follow-up point was 1.91 (95% Confidence Interval = 1.63 - 2.19). (Figure 5)
Table 4 summarizes the effects obtained in each of the analyses. (Table 4)
DISCUSSION
The use of endoscopic techniques for the treatment of adjacent-level disease has become increasingly prevalent in the literature, largely because of their great ability to promote clinical improvement associated with a low morbidity rate and low complication rate. The present study shows that endoscopic techniques for treating adjacent-level disease had a low complication rate (0.094) and could bring ODI and VAS scores down to low values.
Recent studies have demonstrated the efficacy of endoscopy in approaching adjacent-level disease, showing its advantages in terms of shorter recovery time, reduced postoperative pain, and preservation of adjacent anatomical structures.3
In a 2024 study, Kapetanakis et al. demonstrated that endoscopic techniques can significantly benefit complex cases, such as diseases of the adjacent level and foraminal stenosis associated with degenerative scoliosis.16
In addition, Wang et al., 2023, in a systematic review and meta-analysis study, pointed out that endoscopy techniques can promote a significant improvement in quality of life outcomes, as well as being associated with low complication rates (0.95%). These results were similar to those found in this study, although the studies’ analyses differed.2
In addition to the clinical benefits, endoscopy can also have economic advantages. In a study by Cheung et al., 2020, the authors showed that hospital costs and length of stay were lower in patients treated with endoscopic techniques, reflecting a favorable cost-benefit ratio.17
Limitations
This study has limitations, such as the exclusion of studies in languages other than Portuguese or English, which may lead to the exclusion of some studies that could influence the outcomes analyzed in this study. In addition, this study did not differentiate between the subgroups of endoscopic techniques used to treat adjacent diseases, thus not allowing a detailed view of the difference the different types of techniques can bring to the treatment effect. However, as many studies did not divide the patients between the different technique groups, the subgroup analysis would present a few studies per group. Hence, the authors opted to do only the generalized analysis.
CONCLUSION
This study shows that using endoscopic techniques to treat adjacent-level disease can be an effective method for resolving patients’ pain (improvement in pain scores and functional scores) and is associated with a low complication rate per 1000 patients (0.094).
However, the quality of the included studies was low, and there was great heterogeneity between them. Therefore, higher-quality studies are needed to better clarify the true effect of endoscopy for the treatment of adjacent-level disease.
Future studies comparing the effect of different endoscopy techniques on the different levels affected by adjacent-level disease are necessary to help surgeons decide on the best surgical option.
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Study conducted by the Barretos, São Paulo, Brazil.
REFERENCES
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Edited by
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Reviewed by:
Alexandre Fogaça Cristante
*If possible, indicate the number of documents identified by each database or protocol searched (rather than just the total number of all databases/protocols registered). **If automated tools were used, indicate how many documents were deleted by human hands and how many were deleted using automated tools. Translated by: Verónica Abreu*, Sónia Gonçalves-Lopes*, José Luís Sousa* and Verónica Oliveira / *ESS Jean Piaget - Vila Nova de Gaia - Portugal Of: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. Doi: 10.1136/bmj.n71.
IC: Confidence interval. N: Number of surgeries.
DP: Standard Deviation, CI: Confidence interval, MRAW: Untransformed average, ODI: Oswestry disability index.
DP: Standard Deviation, CI: Confidence interval, MRAW: Untransformed average, VAS: Visual analog pain scale.
DP: Standard Deviation, CI: Confidence interval, MRAW: Untransformed average, VAS: Visual analog pain scale.