Original Investigation | Özgün Araştırma GMJ 2024;35:30-37

DOI: 10.4274/gmj.galenos.2023.3699

Microdiscectomy and Minimally Invasive Discectomy Using a Tubular Retractor

System for Lumbar Disc Herniation: A Comparative Study
Lomber Disk Hernisinde Tübüler Retraktör Sistemi Kullanılarak Mikrodiskektomi ve Minimal İnvaziv
Diskektomi: Karşılaştırmalı Bir Çalışma

Keerthan Ranga Nayak U1, Shyamasunder N. Bhat2, Nishanth Ampar2, Raghuraj S. Kundangar2
1Department of Orthopaedics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
2Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India

ABSTRACT ÖZ
Objective: The findings of clinical research comparing microdiscectomy Amaç: Mikrodiskektomi ile minimal invaziv yaklaşımı karşılaştıran klinik
and a minimally invasive approach are ambiguous or inconsistent. araştırmaların bulguları belirsiz veya tutarsızdır. Bu nedenle lomber
Therefore, we compared the two interventions in terms of their clinical, disk hernisi için iki girişimi klinik, radyolojik ve fonksiyonel sonuçlar
radiological, and functional outcomes for lumbar disc herniation. açısından karşılaştırdık.
Methods: Seventy-eight patients who underwent microdiscectomy Yöntemler: Tek düzeyde tübüler retraktörler kullanılarak
and minimally invasive discectomy (MID) using tubular retractors at mikrodiskektomi ve minimal invaziv diskektomi (MİD) uygulanan
a single level were prospectively followed up. The visual analogue 78 hasta prospektif olarak takip edildi. Radiküler ağrının şiddetini
scale (VAS) was used to assess the intensity of radicular pain. Clinical değerlendirmek için görsel analog skala (VAS) kullanıldı. Klinik
evaluation involved the straight leg raising test and the assessment of değerlendirme düz bacak kaldırma testini ve motor ve duyu
motor and sensory functions. We used the Oswestry Disability Index fonksiyonlarının değerlendirilmesini içeriyordu. Fonksiyonel
to assess functional outcomes. Instability was assessed by measuring sonuçları değerlendirmek için Oswestry Engellilik İndeksini kullandık.
the angular rotation and sagittal translation in dynamic lateral İnstabilite, dinamik lateral radyografilerde açısal rotasyon ve sagittal
radiographs. The approaches were compared in terms of the length translasyonun ölçülmesiyle değerlendirildi. Yaklaşımlar kesi uzunluğu,
of incision, surgical duration, blood loss, length of hospitalization, and cerrahi süre, kan kaybı, hastanede kalış süresi ve komplikasyonlar
complications. açısından karşılaştırıldı.
Results: The most commonly herniated disc was L4-L5. VAS significantly Bulgular: En sık bel fıtığı L4-L5 idi. Bir ay içinde mikrodiskektomiye
(p=0.0001) improved with MID using tubular retractors than with göre tübüler retraktörlerin kullanıldığı MID ile VAS anlamlı
microdiscectomy in one month. The incision length required was düzeyde (p=0,0001) düzeldi. Gerekli insizyon uzunluğu anlamlı
significantly (p=0.05) smaller and the intraoperative blood loss was derecede (p=0,05) daha kısaydı ve intraoperatif kan kaybı MİD için
lesser for MID than for microdiscectomy. There was no spinal instability mikrodiskektomiye göre daha azdı. Son takibin sonunda her iki grupta
in either group at the end of the final follow-up. Although there was no da omurga instabilitesi görülmedi. Klinik sonuçlarda anlamlı bir fark
significant difference in the clinical outcome, the functional outcome olmamasına rağmen, 1 yıllık takipte her iki grupta da fonksiyonel
improved in both groups at the 1-year follow-up, and the incidence of sonuçlar iyileşti ve postoperatif komplikasyon görülme sıklığı gruplar
postoperative complications was similar between the groups. arasında benzerdi.
Conclusion: Microdiscectomy and MID are comparable procedures Sonuç: Mikrodiskektomi ve MİD, MİD’de daha yüksek intraoperatif
with comparable results, with a tendency for higher intraoperative komplikasyon eğilimi gösteren, karşılaştırılabilir sonuçlara sahip
complications in MID. karşılaştırılabilir prosedürlerdir.
Keywords: Durotomy, lumbar disc herniation, microdiscectomy, Anahtar Sözcükler: Durotomi, lomber disk hernisi, mikrodiskektomi,
minimally invasive discectomy, tubular retractors minimal invazif diskektomi, tübüler retraktörler

Address for Correspondence/Yazışma Adresi: Dr. Shyamasunder N. Bhat MS (Ortho), Professor and Head, Department of Orthopaedics, Kasturba Medical
College, Manipal, Manipal Academy of Higher Education, Manipal, India
E-mail / E posta: [email protected]
ORCID ID: orcid.org/0000-0001-9545-4838
©
Copyright 2024 by Gazi University Faculty of Medicine / Gazi Medical Journal is published by Galenos Publishing House. Licensed
under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 (CC BY-NC-ND) International License
©
Telif Hakkı 2024 Yazar. Gazi Üniversitesi Tıp Fakültesi adına Galenos Yayınevi tarafından yayımlanmaktadır. Creative Commons Received/Geliş Tarihi: 03.10.2022
Atıf-GayriTicari-Türetilemez 4.0 (CC BY-NC-ND) Uluslararası Lisansı ile lisanslanmaktadır.
Accepted/Kabul Tarihi: 12.07.2023

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INTRODUCTION Surgical Techniques

Lumbar disc herniation (LDH) is defined as the localized displacement Microdiscectomy Group (Group A)
of disc material beyond the normal intervertebral disc space margins,
The procedure was performed in the prone position under general
resulting in lower back pain and radiculopathy (1,2). On extrusion,
anesthesia. The operative level was marked using a fluoroscope.
the disc material can compress and damage-sensitive nerve roots,
The subcutaneous plane was infused with 1:1,00,000 adrenaline.
resulting in paraesthesia and weakness of one or both legs.
At the affected level, a standard midline posterior approach was
The natural history of LDH is discerned by intermittent symptoms used. Subperiosteal dissection was performed on the side of the
with improvement in most cases, which can make any intervention radiculopathy, and fenestration was performed. Using a nerve
appear successful. Generally, patients with acute LDH are treated retractor, the lateral border of the traversing root was medially
with bed rest and analgesics. If non-operative treatment fails, retracted. The herniated disc fragments were then identified and
surgical management is considered. The surgical technique for LDH removed. Pituitary forceps were used to remove loose fragments
was first described in 1932, (3) and has greatly evolved since Yasargil from the disc space (Figure 1). Thorough saline irrigation was used
et al. (4) first used a microscope to perform lumbar disc surgery in to identify any retained disc fragments in the epidural space. Nerve
1967. In 1997, Smith and Foley (5) developed a technique using roots were confirmed to be free. The wound was closed in layers
tubular retractors. It involves inserting sequential dilators to split over a drainage tube.
muscles and reach the disc, a so-called minimally invasive surgery. Minimally Invasive Discectomy Using a Tubular Retractor
Microdiscectomy and minimally invasive discectomy using a Group (Group B)
tubular retractor [minimally invasive discectomy (MID)] are two
The patient was positioned as described above. A paramedian
commonly used surgical techniques for the management of LDH. incision lateral to the midline was made over the affected side using
Microdiscectomy is still considered the gold standard method for a transmuscular approach. Serial dilators were then inserted and
treating LDH. Very few studies have compared microdiscectomy and docked on the lower border of the lamina. A flexible arm was used
MID in the Indian population. The study compared the clinical and to insert and secure a 22-mm tubular retractor to the operating
functional outcomes between the two groups. table. Fluoroscopic images were obtained to confirm the extent
of surgery. The remaining muscle fibers in the surgical field were
MATERIALS AND METHODS cleared using electrocautery. A laminotomy was performed using a
We conducted a prospective study on all adult patients aged 18 to high-speed burr. The lateral border of the traversing nerve root was
60 years who presented to our hospital with lumbar radiculopathy also identified. Wanding was performed as required to decompress
with prolapse, extrusion, or sequestration of the intervertebral various areas at the level of surgery. Using a Penfield, the dural
disc at any single level between L3-L4, L4-L5, or L5-S1 on MRI of sheath and nerve root were retracted medially. Disc forceps were
the lumbosacral spine and who did not improve after 2 months of
medical management. Patients with multiple-level intervertebral
disc prolapse, prior spinal surgery, radiological instability at the
same level, spinal canal stenosis, recurrent LDH, and cauda equina
syndrome were excluded. Finally, 78 patients were included in the
study, with a 1-year follow-up period. They were divided into two
groups by convenience sampling. Both surgeries were performed
by an experienced senior surgeon. Thirty-seven and 41 patients
underwent microdiscectomy and MID, respectively, between 2018
and 2020.
The severity of radicular pain was measured using the visual analog
scale (VAS), which ranged from 0 (no discomfort) to 10 (extreme
pain; worst pain ever experienced). Straight leg raising test (SLRT),
motor power, and sensory assessments were used in clinical
evaluation. The Oswestry Disability Index (ODI) was used to assess
functional outcomes. The gauze VAS was used to estimate blood
loss by determining the percentage saturation of blood in the gauze.
Anteroposterior and lateral lumbar spine radiographs (flexion and
extension views) were used to assess spinal instability using the
criteria of Dupuis et al. (6). Translation >4 mm of vertebral body
width was defined as sagittal translatory instability, and angular
rotation >10° was defined as sagittal angular instability. Figure 1. Steps of microdiscectomy (A) Lamina exposed, (B) Extruded
The Kasturba Hospital Institutional Ethics Committee approved the disc beneath the root, (C) Free nerve root after discectomy, (D) Incision
study (approval number: IEC: 586/2018, date: 19.09.2018). measured before closure.

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used to remove the herniated disc material and loose fragments The mean VAS score improved significantly in the MID group at
(Figure 2). The wound was closed in layers over a surgical drain. immediate postoperative and 1-month follow-up (2.68±1,753)
The duration of surgery, incision length, blood loss, intraoperative compared with the microdiscectomy group (3.38±1,361) (p<0.05).
complications such as nerve root injury, conversion to open Furthermore, at the end of one year, VAS score improvement was
procedure, and dural tear if any were noted. similar in both groups, and the VAS score improved significantly from
Patients were followed up at one month, six months, and one year preoperative to postoperative follow-up in both groups (p<0.01)
after surgery. At each visit, the intensity of pain was assessed using (Figure 3).
VAS. The SLR test, motor power, and sensory assessments were The mean preoperative ODI score was 48.95±11.79 in the
performed. Functional outcome was evaluated using the ODI score. microdiscectomy group, whereas it was 51.95±13.52 in the MID
Radiological assessment was performed at the end of one year to group, depicting severe disability in both groups. A significant
assess spinal instability. improvement was noted within both groups when the pre-operative
and postoperative follow-up ODI scores were compared (p<0.01).
Statistical Analysis
However, there was no difference in the mean ODI scores at
The efficacy of microdiscectomy and MID in single-level LDH was postoperative follow-up between both groups (p=0.80) (Figure 4).
compared using the SPSS software (Released 2006, Version 15.0.
Significant improvements in SLRT and Lasegue’s sign (p<0.01) were
Chicago, SPSS Inc.). The VAS score and motor weakness were
noted from the pre-operative period to postoperative follow-up. No
compared using the Mann-Whitney U test. The VAS score, motor
difference in SLRT was noted at the end of one year in either group
weakness, and sensory impairment were compared preoperatively
(p=0.919) (Table 2).
and postoperatively using the Wilcoxon signed-rank test. The ODI and
SLRT scores were compared between the two groups using the t-test. At the end of one-year, both groups showed comparable sensory
ODI and SLRT were compared preoperatively and postoperatively and motor power improvements (MRC grading) (p<0.01) (Table 3,
using Bonferroni post-hoc analysis. A t-test was used to compare 4). There was no disability due to motor and sensory deficits among
Lasegue’s test results, length of hospital stay, and average time to the operated patients in either of the groups.
return to work. Differences were considered statistically significant The surgical incision length was measured using a measuring scale.
at p<0.05. Mean values are presented as mean ± standard deviation. The mean surgical incision length in the microdiscectomy group

RESULTS Table 1. Baseline demographics of patients who underwent surgery

in groups A and B
Seventy-eight patients diagnosed with LDH who underwent either
microdiscectomy or MID during the study period were analyzed. We Group A Group B
Characteristics Parameter
(n=37) (%) (n=41) (%)
prospectively studied all 78 patients and compared both groups: 37
patients underwent microdiscectomy and 41 underwent MID (Table 1). Male (n=54) 32 (86.49%) 22 (53.66%)
Sex
The mean age of patients in the microdiscectomy group was 41±10.03 Female (n=24) 05 (13.51%) 19 (46.34%)
years and 41.78±11.29 years in the MID group. However, this was L3-L4 1 (2.7%) 0 (0%)
not significantly different between the two groups (p=0.749). Among Level L4-L5 23 (62.2%) 18 (43.9%)
affected patients, the most common disc involved in herniation was L5-S1 13 (35.1%) 23 (56.1%)
L4-L5. Only one patient had L3-L4 disc prolapse (Table 1).
Right 12 (32.4) 24 (58.5%)
Radiculopathy
Left 25 (67.6) 17 (41.5)

Figure 2. Steps of MIS with tubular retractor (A) image intensifier to

identify level, (B, C) fluoroscopy images confirming the docked level, (D)
dura retracted, (E) retraction of traversing root exposing the herniated Figure 3. Visual analog scale depicting the severity of pain between the
disc, (F) Incision size. microdiscectomy and MID groups.
MIS: Minimally invasive surgery. MID: Minimally invasive discectomy.

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was 4.42±1.25 cm compared with that in the MID group, which was during surgery. However, dural repair was not attempted because
2.45±0.41 cm (Table 5). The MID group had a significantly smaller the tears were minor. No complications associated with dural tears
incision than the microdiscectomy group (p<0.01). The difference in were noted in these patients. One patient (1.28%) in the MID group
the mean intraoperative blood loss between the microdiscectomy had a postoperative surgical site infection that was managed by
and MID groups was significant (79.38±24.30 mL vs. 59.02±19.31 regular wound dressings and oral antibiotics; the infection resolved
mL, p=0.005) (Table 5). Salient differences in the average duration within 2 weeks. In one patient in the microdiscectomy group, we
of surgery were not observed among the microdiscectomy group noted complex regional pain syndrome-like features immediately in
(75±16.46 min) or the MID group (75.85±21.82 min) (p=0.847). No the postoperative period, which were managed with gabapentin and
significant difference was observed in the length of hospital stay NSAIDS; the patient improved within 6 weeks (Table 6). Both groups
between the microdiscectomy and MID groups (2.92±1.06 days vs. had no radiological instability at the end of follow-up. Overall, both
3.59±3.58 days, p=0.279). The average time to return to work was interobserver and intraobserver agreement for the parameters
calculated for both groups. The difference in the average time to used to perform the radiological assessment for instability was high
return to work between the microdiscectomy and MID groups was (p<0.01) (Figure 5).
not significant (1.27±1.31 months vs. 1.29±1.69 months, p=0.948).
One patient with root injury was noted to have foot drop in the MID DISCUSSION
group; however, the patient recovered at the 6-month follow-up. Microdiscectomy and MID are two different surgical techniques
Three (3.85%) and eight (10.25%) patients in the microdiscectomy for treating LDH; the former is currently the gold standard for
and MID groups, respectively, underwent incidental durotomies management. Laminectomy were modified into microdiscectomies
with the advent of magnification devices such as microscopes
and loupes. MID has emerged as an alternative technique for the
surgical management of LDH. It is said to have produced equal or
better results than microdiscectomy, although there is insufficient
evidence to support this claim. The principle behind the tubular
retractor system is to replace muscle dissection with the muscle-
splitting transmuscular approach, which is less traumatic to soft
tissues and has a faster recovery rate. A review of related literature
has shown ambiguous outcomes (7,8). Current studies on surgical
approaches for LDH are suffused with obscurity, making it difficult
for surgeons to accept MID as the standard approach. We attempted
to determine whether either approach has a significant advantage
over the other. In our prospective comparative non-randomized
Figure 4. Bar diagram showing the functional ODI score between the observational study, we assessed the efficacy of surgery in single-
microdiscectomy and MID groups. level LDH.
MID: Minimally invasive discectomy, ODI: Oswestry Disability Index. Clark et al. (7) and Rasouli et al. (8), observed that the MID group
had a higher VAS score for leg pain after one year. At one month after
Table 2. Comparison of the straight leg raising test between groups
surgery, the alleviation of pain was more significant in the MID group
A and B
than in the microdiscectomy group. However, these appreciable
SLRT in degrees (mean ± SD) differences were not observed at the end of one year. The alleviation
Group A Group B of pain following surgery was significant in both groups, as reported
Pre-operative 37.03±9.68 42.44±10.44 previously (7,9,10).
1 month 77.84±6.72 74.39±11.63 A significant improvement in ODI scores was noted in both groups
Post-operative 6 months 82.7±6.52 80.24±14.58 during follow-up. However, we did not find any significant difference
1 year 86.67±4.82 86.52±4.87 between the groups in the post-operative ODI scores or improvement
in the scores in our study. In studies by Lau et al. (11), Harrington and
SD: Standard deviation, SLRT: Straight leg raising test.
French (12), Ryang et al. (9), and Teli et al (10), there was a significant

Table 3. Comparison of sensory deficits in groups A and B

Number of patients (%)
Group B Group B
Sensory grading Grade 1 Grade 2 Grade 1 Grade 2
Pre-operative 22 (59.5%) 15 (40.5%) 24 (58.5%) 17 (41.5%)
Immediate 23 (62.2%) 14 (37.8%) 23 (56.1%) 18 (43.9%)
1 month 23 (62.2%) 14 (37.8%) 23 (56.1%) 18 (43.9%)
Post-operative
6 months 8 (21.6%) 29 (78.4%) 11 (26.8%) 30 (73.2%)
1 year 3 (8.1%) 21 (56.8%) 4 (9.8%) 19 (46.3%)

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Table 4. Comparison of motor deficits in groups A and B

Time points
Category MRC grading Immediate
Pre-operative, Post-operative at Post-operative at 6 Post-operative at
post-operative,
n (%) 1 month, n (%) months, n (%) 1 year, n (%)
n (%)
Grade 0 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Grade 1 1 (2.7%) 2 (5.4%) 2 (5.4%) 1 (2.7%) 1 (2.7%)
Grade 2 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Group A
Grade 3 2 (5.4%) 2 (5.4%) 2 (5.4%) 1 (2.7%) 1 (2.7%)
Grade 4 5 (13.5%) 4 (10.8%) 4 (10.8%) 5 (13.5%) 5 (13.5%)
Grade 5 29 (78.4%) 29 (78.4%) 29 (78.4%) 30 (81.1%) 30 (81.1%)
Grade 0 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Grade 1 1 (2.4%) 1 (2.4%) 1 (2.4%) 0 (0%) 0 (0%)
Grade 2 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Group B
Grade 3 4 (9.8%) 4 (9.8%) 4 (9.8%) 4 (9.8%) 4 (9.8%)
Grade 4 9 (22%) 9 (22%) 9 (22%) 5 (12.2%) 5 (12.2%)
Grade 5 27 (65.9%) 27 (65.9%) 27 (65.9%) 32 (78%) 32 (78%)
MRC: Medical Research Council.

Table 5. Primary outcome parameters and significance

Parameter Group A Group B p-value
Mean ± SD 4.42±1.25 2.45±0.41
Incision length (cm) Minimum 4 2.32 0.0001**
Maximum 4.84 2.58
Mean ± SD 79.38±24.30 59.02±19.31
Intraoperative blood loss (mL) Minimum 65.28 52.93 0.05*
Maximum 81.48 65.12
Mean ± SD 75.00±16.46 75.85±21.82
Duration of surgery (minutes) Minimum 69.51 68.97 0.847
Maximum 80.49 82.74
Mean ± SD 2.92±1.06 3.59±3.58
Hospital stay (days) Minimum 2.56 2.46 0.279
Maximum 3.27 4.71
Mean ± SD 1.27±1.31 1.29±1.69
Return to work (months) Minimum 3.84 3.76 0.948
Maximum 4.71 4.83
*
Significant, **Highly significant, SD: Standard deviation.

difference in ODI scores during postoperative follow-up when

Table 6. Various complications in groups A and B compared between the groups. Moreover, no marked difference
Number of patients (%) was noticed in terms of return to work between the two groups in
Complications Group A Group B our study, as highlighted in similar studies (13,14).
Nerve root injury 1 (2.7%) 0 (0%) The incision length, smaller was smaller in the MID group than in the
Dural tear 3 (8.1%) 8 (19.5%) microdiscectomy group; hence, intraoperative blood loss was much
Surgical site infection 0 (0%) 1 (2.4%) lesser in the former. Moliterno et al. (15) and Lau et al. (11), found
Other patient-related impairments Group A Group B similar results. A smaller incision in MID patients compared with
Complex regional pain syndrome 1 (2.7%) 0 (0%) microdiscectomy patients significantly reduced intraoperative blood
Postoperative sciatic scoliosis 1 (2.7%) 0 (0%) loss. However, studies by Harrington and French (12), Ryang et al.
Hamstring tightness 9 (24.32%) 5 (12.19%) (9), and Arts et al. (14), showed no difference between both groups
in terms of operative blood loss.

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When comparing the surgical time, Lee et al. (13), and Arts et al. (14) When comparing the groups, Lau et al. (11), Lee et al. (13), and
reported that MID had significantly shorter operative times than Bhatia et al. (17) discovered that there was no difference in
microdiscectomies. However, we found no significant difference neurologic improvement in terms of sensory and motor power.
in operation times between patients who underwent MID and In our study, all individuals with neurological deficits in terms of
microdiscectomy, indicating that both approaches took similar time. sensory and motor power improved dramatically over the course of
Lau et al. (11), Harrington and French (12), and Ryang et al. (9), a year. However, there were no significant differences between both
found results similar to ours. groups. Intraoperative nerve root injury is a possible complication
In terms of hospital stay, Lee et al. (13) and German et al. (16) of discectomy. Overdevest et al. (18) found three cases of nerve
reported that patients undergoing MID had a significantly shorter root injury in each group. Bhatia et al. (17) observed one patient
hospital stay than those undergoing microdiscectomy. The duration with nerve root injury in the MID group who had great toe paresis
of stay in our study did not significantly differ between the two and eventually recovered within 2 months. In our study, one patient
groups. However, one patient in the MID group stayed for 25 days in (2.7%) in the microdiscectomy group had a nerve injury, and paresis
the hospital because of surgical site infection. occurred in the ankle during the postoperative period. He was
observed with ankle foot orthosis and physiotherapy; at the end of
6 months, motor power had improved. However, there was no such
complication in the MID group.
Wrong-level surgery is a known complication during discectomy;
the incidence is higher in MID surgery because there can be errors
during tubular retractor placement at the intended site of surgery.
In Irace and Corona (19), no patient demonstrated an incorrect level
or side clinically or radiologically in microdiscectomy. Kulkarni et al.
(20) identified one (0.5%) wrong level among 188 cases of tubular
discectomy, which was later corrected in revision surgery. Overdevest
Figure 5. (A, B) Evaluation of anterior and posterior angular rotation and et al. (18) found that five patients who underwent microdiscectomy
(C, D) evaluation of sagittal translation in flexion and extension views and one patient who underwent tubular discectomy had wrong-

Table 7. Literature review of related studies

Total
Eligible VAS at the final ODI at final
Study Study type Study complications Conclusion
(n) follow-up follow-up (%)
(n)
Tubular discectomy
Tubular resulted in less
Arts et al. 14.1 v/s 18.3
RCT discectomy v/s 328 19 v/s 14 favorable results for
(14) mm
microdiscectomy leg pain, back pain,
and recovery.
Microdiscectomy The rate of recovery
Bhatia et al.
Retrospective v/s tubular 148 1.82 v/s 1.28 14 v/s 14 6 v/s 16 was significantly faster
(17)
discectomy for TD than for MD.
No significant
Lau et al. MIS v/s 4 (20%) v/s 6
Retrospective 45 difference between
(11) microdiscectomy (24%)
the two groups
Tubular Both were found
Asati et al.
Retrospective discectomy v/s 414 1.68 v/s 1.70 14 v/s 13 24 v/s 50 to have similar
(25)
microdiscectomy outcomes.
Minimally invasive
Outcome measures
Teli et al. microdiscectomy
RCT 142 2 v/s 2 (Same) 14 v/s 16 18 v/s 10 were equivalent in
(10) v/s open
both groups
microdiscectomy
The early
Subperiosteal v/s postoperative
Brock et al. 91.5% (n=54) 20% v/s 25.7%
RCT transmuscular 141 outcome was
(26) v/s 97% (n=64) Improvement
approach equivalent in both
groups
VAS: Visual analogue scale, ODI: Oswestry Disability Index, TD: Tubular discectomy, MD: Microdiscectomy, MIS: Minimally invasive surgery, RCT:
Randomized controlled trial.

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level surgery. In our series, in one patient undergoing MID, the CONCLUSION
operating surgeon performed fenestration at a lower level instead of
Patients undergoing microdiscectomy and MID with tubular
the pathological level. The status was confirmed by fluoroscopy. The
retractors had similar outcomes. Patients in both groups had
correct level was then identified, and fenestration and discectomy
were performed. Radiological localization and confirmation of the comparable pain scores and ODI scores at the end of the 1-year
level of retractor placement are of paramount importance to avoid follow-up. Intraoperative complications are slightly higher in MID
these errors. patients. Intraoperative blood loss, immediate post-operative pain
and length of surgical scar were significantly less in the MID group.
According to Overdevest et al. (18), Bhatia et al. (17), and
Dasenbrock et al. (21), incidental durotomies occur significantly Ethics
more frequently during MID than during microdiscectomy. There
Ethics Committee Approval: The Kasturba Hospital Institutional
was no statistical difference in the incidence of dural tears between
Ethics Committee approved the study (approval number: IEC:
the microdiscectomy and MID groups, according to Lee et al. (13)
586/2018, date: 19.09.2018).
and Rasouli et al. (8). Due to the limited surgical field for dural
repair in MID, it may sometimes be necessary to convert to an open Informed Consent: Prospective study.
microdiscectomy for wider access as it will be difficult to perform Peer-review: Externally peer-reviewed.
dural repairs through the tubular retractors. Although incidental
autotomies were identified in both groups in our study, they were Authorship Contributions
slightly more frequent in patients with MID (Table 6), but there was Concept: S.N.B., Design: S.N.B., Analysis or Interpretation: K.R.N.,
no significant difference between both groups. Because the tears S.N.B., N.A., Literature Search: K.R.N., R.K.K., Writing: S.N.B., N.A.,
were minor, no dural repair was attempted. R.K.K.
In their study, Overdevest et al. (18) found no postoperative wound Conflict of Interest: No conflict of interest was declared by the
complications in either of the procedures. Bhatia et al. (17) observed authors.
one patient in each group with a surgical site infection. Teli et al. (10)
reported similar results, with no differences between the two groups. Financial Disclosure: The authors declared that this study received
One patient in the MID group (2.4%) had postoperative surgical site no financial support.
infection and underwent wound exploration on postoperative day 2.
Although there was no growth on culture, the histopathology report
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