Survey Research of Patient’s Preference on Choosing Microscopic Or Endoscopic Spine Surgery for Lumbar Discectomy

Gun Keorochana, Chaiwat Kraiwattanapong, Thamrong Lertudomphonwanit, Umaporn Udomsubpayakul, Pittavat Leelapattana, Pongsthorn Chanplakorn, Nutthee Wannaratsiri, Tulyapruek Tawonsawatruk



There are several surgical methods of lumbar discectomy which provide the similar clinical outcomes. There is no clear evidence for how to select the procedures. To better understand the patient’s opinion and decision process in the selection of surgical methods between microscopic lumbar discectomy (MLD) and endoscopic lumbar discectomy (ELD).


The evolution of minimal invasive surgery has been widespread implemented in almost every surgery. With the development of new instrumentations, there are several advanced techniques which seem to improve the outcome of surgery. In spine surgery, there were evidences that suggested the outcome of minimal invasive spine surgery had significantly better outcomes than conventional surgery [1, 2]. Microscopic lumbar discectomy (MLD) and endoscopic lumbar discectomy (ELD) are 2 major minimal invasive spine surgeries for lumbar disc herniation. MLD was introduced by Caspar [3] and Yasagil [4]. The procedure consists of a small surgical wound, preserved paraspinal muscles and more targeted surgical exposure. It is considered a standard treatment due to the reduction of invasiveness and complications when compared with conventional open surgery. ELD was evolved from percutaneous chemonucleolysis which was firstly reported by Lyman Smith. Hijikata developed tubes which could pass through the posterolateral annulus of lumbar intervertebral disc under fluoroscopy. Percutaneous nucleotomy then was firstly done in 1975 [5]. Later, the first endoscopic views of a herniated nucleus pulposus were published by Kambin et al. [6] With the advanced technology of the camera and medical instruments, ELD is practical and gaining popularity. Several literatures have shown similar outcomes of ELD and MLD [7–9].

Materials and method

Cross sectional data survey was performed after approval for the study was obtained from Committee on Human Rights Related to Research Involving Human Subjects, Faculty of Medicine Ramathibodi Hospital, Mahidol University. Written informed consent was signed in all participants in order to answer the questionnaires. Patients who came for treatment at Spine Clinic, Department of Orthopaedics, Ramathibodi Hospital during August, 2018- July, 2019 were asked to participate in this study if they met the inclusion criteria. After providing informed consent, all respondents received the summary information sheet and survey questionnaire. After the patients read the summary information sheet, they were asked to complete the anonymous questionnaire.
The inclusion criteria were the patients who had low back pain with or without radiculopathy caused by degenerative spine problems. We included the participants from our spine clinic, who never got spine surgery and those who underwent ELD or MLD at least 6 weeks ago. We excluded the patients who were diagnosed with spinal infection, spinal metastasis, inflammatory spine diseases and spine trauma.


All orthopedic surgeons who were asked to evaluate the summary information sheet cooperated and provided response. Nine out of ten (90%) classified the summary sheet as “appropriate”, while the other orthopedic surgeon classified it as “appropriate after some adjustment”. Also, eighty percent of the patients (12 out of 15) classified the summary sheet as “clearly understand”. According to our pre-specified quality parameter, then the summary information sheet was considered appropriate for providing the knowledge to the patients.


There are several studies comparing MLD and ELD for lumbar disc herniation [5, 7, 8]. According to the randomized controlled study of Ruetten et al, both treatments showed comparable significantly improved clinical outcome when compared by Visual Analog Scale (VAS) pain scores, Oswestry Disability Index (ODI) scores and North American Spine Society Instrument scores. ELD was performed with shorter operative time, lesser intraoperative blood loss, and fewer complication rates when compared with MLD, while the reoperation rate was not different [10]. In contrast, Chen et al. reported over the 2-year follow-up period ELD did not show superior clinical outcomes and did not seem to be a safer procedure for patients with lumbar disc herniation compared with microendoscopic discectomy. ELD had inferior results for median disc herniation and had superior outcomes for far-lateral disc herniation. The reasons were narrow neural foramen and small working cannula of endoscope had an effect on difficultly to completely remove large central disc herniation [11].


About two thirds of the participants preferred endoscopic spine surgery after reading the summary evidence information. Basic demographic data does not influence the surgical method selection. The most important factor in MLD group was outcomes of treatment while the most important factor in ELD group was wound size. Most of the patients who had experience in lumbar discectomy will select the same operation again and will recommend the same operation to other patients. This study emphasized the patients’ perspective after they received evidence-based information for selecting surgical methods.

Citation: Keorochana G, Kraiwattanapong C, Lertudomphonwanit T, Udomsubpayakul U, Leelapattana P, Chanplakorn P, et al. (2023) Survey research of patient’s preference on choosing microscopic or endoscopic spine surgery for lumbar discectomy. PLoS ONE 18(4): e0283904.

Editor: Thamer Hamdan, Saint George’s Hospital Medical School: St George’s University of London, IRAQ
Received: April 4, 2022; Accepted: March 21, 2023; Published: April 6, 2023

Copyright: © 2023 Keorochana et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

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