
==== Front
J Orthop Surg Res
J Orthop Surg Res
Journal of Orthopaedic Surgery and Research
1749-799X
BioMed Central London

39237977
5043
10.1186/s13018-024-05043-w
Research Article
Percutaneous endoscopic interlaminar discectomy with patients’ participation : better postoperative rehabilitation and satisfaction
Liu Wangxin 1
Liu Lei 2
Pan Zhicheng zzypanzc@163.com

1
Gu Enpeng gu840134@163.com

3
1 https://ror.org/05dfcz246 grid.410648.f 0000 0001 1816 6218 Tianjin University of Traditional Chinese Medicine, No.10 Poyang Lake Road, Tianjin, 301617 People’s Republic of China
2 Department of Orthopedic, Chuzhou Chinese and Western Medicine Hospital, No.788 Huifeng East Road, Chuzhou, 239000 Anhui People’s Republic of China
3 https://ror.org/00bhbea87 grid.488543.6 Department of Orthopedic, The Second Affiliated Hospital of Tianjin University of TCM, No.69 Yield-increasing Road, Tianjin, 300150 People’s Republic of China
6 9 2024
6 9 2024
2024
19 5471 8 2024
31 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Object

Evaluation of the impact of patients’ participation on postoperative recovery and satisfaction who underwent the Percutaneous Endoscopic Interlaminar Discectomy(PEID).

Methods

We collected data from sixty-nine patients who underwent PEID surgery at Chuzhou Chinese and Western Medicine Hospital between January 2020 and December 2022. All patients had L5/S1 lumbar disc herniation and met the inclusion and exclusion criteria. The patients were divided into two groups: non-communication group (n = 33) and communication group (n = 36). The division was made based on whether the patients had preoperative surgical video viewing and intraoperative communication. We compared the baseline data, surgical time, VAS score, lumbar JOA score, surgical complications, and patient satisfaction between the two groups.

Result

The communication group showed better pain control and functional recovery in the early postoperative period. The communication group had better VAS scores on the first day and month after surgery, as well as JOA scores on the first week and month after surgery, with statistically significant differences (P < 0.05). There was no significant difference in hospital stay, VAS score, JOA score, and postoperative complications between the two groups of patients at 3 and 6 months after surgery. The communication group had higher patient satisfaction (P < 0.05).

Conclusion

Preoperative surgical video viewing and intraoperative communication by PEID patients can alleviate pain, accelerate functional recovery, improve symptoms, and increase patients’ satisfaction. We need to do more work to develop this new model.

issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
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pmcIntroduction

Lumbar disc herniation(LDH) is one of the most common spinal diseases, characterized by low back pain, sciatica, numbness, weakness, and pain in the lower limbs [1, 2]. Although there are many non-surgical treatment methods, and they are also the first choice for doctors and patients, about 10–15% of patients still require surgery [3]. Thanks to the development and progress of technology, instruments, and anatomical knowledge, the surgical method has shifted from traditional open surgery to minimally invasive surgery, aiming to reduce injury, shorten hospital stays, and achieve rapid recovery [4].

Since Kambin experimentally induced arthroscopy to treat LDH, percutaneous endoscopic lumbar discectomy(PELD) has undergone great development rapidly [5]. Percutaneous Transforaminal Endoscopic Discectomy(PTED) and Percutaneous Endoscopic Interlaminar Discectomy(PEID), as the primary surgical methods for minimally invasive spinal surgery, have advantages such as small incision, fast recovery, short hospital stay, and comparable effects to open surgery [6, 7]. As a supplementary surgery for PTED, PEID is more advantageous for treating L5/S1, high iliac, central, and paracentral disc herniation [8, 9].

In recent years, many scholars have conducted research on the effectiveness and safety of two surgical methods, PEID and PTED, but different studies have shown conflicting results [9]. The surgical procedure may impact the patient’s recovery, but controversy remains. We propose a new surgical model that introduces patients to the entire surgical process by playing surgical videos before PEID and allows patients to watch the screen and communicate with the doctor during the surgery. This approach may positively impact building doctor-patient trust, improving patient symptoms, and promoting recovery. We retrospectively studied the medical records of patients undergoing PEID surgery in our hospital over the past three years to evaluate the potential benefits of patient participation in symptom improvement and functional recovery.

Methods

Patient selection

This study was approved by the Ethics Committee of Chuzhou Chinese and Western Medicine Hospital and included patients with informed consent. All methods were performed in accordance with the relevant guidelines and national regulations.We retrospectively collected patients with lumbar disc herniation who underwent PEID surgery at our hospital (Chuzhou Chinese and Western Medicine Hospital) from January 2020 to December 2022. According to whether the patient participated in preoperative surgical video viewing and intraoperative communication, they were divided into non-communication group and communication group.The inclusion criteria are as follows: (1) Symptoms of low back pain, sciatica, lower limb pain, numbness, and weakness. (2) Computer tomography (CT) and magnetic resonance imaging (MRI) confirmed L5/S1 intervertebral disc herniation. (3) Non-surgical treatment failure. (4) The follow-up time exceeds six months. Exclusion criteria: (1) Multiple-level intervertebral disc herniation or combined with lumbar spinal stenosis, lumbar instability, lumbar tuberculosis, etc., affect the judgment of the results; (2) The medical record information is incomplete. 3)Patients who are minors or otherwise unable to cooperate with communication. All patients received follow-up for more than six months, including face-to-face, telephone, and WeChat follow-up.

All patients underwent lumbar epidural anesthesia and prone position surgery, with experienced doctors from the same team performing the surgery. The non-communication group introduced the surgical method before surgery and covered the patient’s field of view with sterile sheets during surgery without communicating with the patient. The communication group watches the entire process of PEID surgery before surgery, with the same team of doctors explaining and answering patient questions. During surgery, patients can watch the screen and communicate with the surgeon.The surgeon informed the patient of the protruding nucleus pulposus and the compressed nerve root accroding to the video and explained the patient‘s problems in detail.

After the surgery, the same amount of mannitol 100 ml was given for swelling reduction, flurbiprofen axetil 50 mg for pain relief, regular dressing changes, and thread removal.Postoperative rehabilitation instructions were the same for both groups. All patients were required to wear a lumbar support when sitting, standing or walking. Early functional rehabilitation exercises were also crucial. Each patient was instructed to perform five sets of 20 bilateral straight leg raises per day in bed. Lumbar weight-bearing was prohibited for six months after surgery to minimize recurrence.The postoperative precautions are guided by personnel from the same nursing team.

Follow-up

Follow-up will be conducted on selected patients who meet the inclusion and exclusion criteria. There are three ways to conduct postoperative follow-up: patients go to the hospital to meet the doctor face-to-face, and the doctor contacts the patient by phone or WeChat.

Outcomes assessment

After obtaining the consent of the ethics committee and the patient, we received the patients’ age, gender, body mass index, education level, surgical time, preoperative VAS score, lumbar JOA score, and surgical complications from the medical record. The postoperative VAS score, lumbar JOA score, and satisfaction were collected face-to-face, via phone, or via WeChat.

Statistical analysis

Statistical comparisons were based on the observed and recorded follow-up data by SPSS 25.0 software for Windows. The descriptive data is represented by mean and standard deviation, and the Shapiro-Wilk test is used to determine whether the econometric data conforms to a normal distribution. The data of the two groups of patients followed the normal distribution.The Independent Samples t-test is used for comparing continuous variables. The Mann-Whitney test is used for comparing ordinal variables.Use the Chi-Squared tests to compare categorical variables. P-values of < 0.05 were considered to be statistically significant.

Result

A total of 75 PEID surgeries under combined lumbar-hard anesthesia were performed from January 2020 to December 2022 at our hospital.One patient with simultaneous surgery on two segments, three patients with combined lumbar instability, and two patients with incomplete follow-up data were excluded. Sixty-nine patients were finally included, and they were categorized into no-communication group (n = 33) and communication group (n = 36) based on their participation in preoperative surgical video viewing and intraoperative communication.The baseline data and preoperative information included are shown in Table 1. There were no significant differences in age, gender, body mass index, education level, preoperative VAS score, and preoperative JOA score between the two groups of patients (Table 1).

The non-communication group had shorter surgical time; the difference was statistically significant (P < 0.05). The communication group had better VAS scores on the first day and month after surgery and JOA scores on the first week and month after surgery, with statistically significant differences (P < 0.05). However, there was no significant difference in hospital stay, VAS scores, and JOA scores at 3 and 6 months after surgery (Table 2).

During the surgery, one patient in the communication group experienced dural tear without cerebrospinal fluid leakage; One patient in the non-communication group experienced postoperative sensory retardation, and one patient experienced dural tear. At follow-up, all patients recovered without recurrence or other adverse events. The patient satisfaction in the communication group was higher (Table 3).

Table 1 Demographic characteristics and preoperative data

Variable N	communication group	non-communication group	P value	
Mean age-yr	43.64±9.51	44.85±9.02	0.561a	
male sex-no. (%)	24(66.7)	21(63.6)	0.792b	
BMI	24.92±2.64	24.62±2.21	0.655a	
Educational level-no. (%)			0.945c	
primary	7(19.4)	6(18.2)		
junior high	10(27.8)	10(30.3)		
senior high	11(30.6)	9(27.3)		
university or above	8(22.2)	8(24.2)		
Preoperative VAS score	6.19±0.66	6.09±0.75	0.551a	
Preoperative JOA score	11.89±2.63	11.24±2.62	0.584 a	
a: Independent Samples t-test; b:Chi-square test; c: Mann Whitney test

Table 2 Intraoperative and postoperative follow-up data

Outcome	communication group	non-communication group	P value	
operative time-min	74.72±13.76	66.64±15.74	0.014a*	
Postoperative hospitalization time-d	4.83±1.36	4.88±1.51	0.897a	
Postoperative VAS scores				
1 day	3.03±0.60	3.64±0.73	0.000a*	
1month	1.20±0.57	1.48±0.56	0.039a*	
3months	0.44±0.60	0.48±0.66	0.793a	
6 months	0.25±0.43	0.27±0.51	0.844a	
Postoperative JOA score				
1week	19.47±2.51	18.00±2.02	0.011a*	
1month	22.89±1.26	22.24±1.21	0.036a*	
3months	24.53±1.40	24.33±1.22	0.549a	
6 months	26.36±0.67	26.27±0.90	0.648a	
a: Independent Samples t-test; *:significant at P<0.05

Table 3 Complications and follow-up satisfaction

Outcome	communication group	non-communication group	P Value	
Complications -no. (%)	1(2.8)	2(6.1)	0.939b	
Satisfaction -no. (%)

Very satisfied

Mostly satisfied

Dissatisfied

Very dissatisfied

	32(88.9)

3(8.3)

1(2.8)

0(0)

	22(66.7)

6(18.2)

5(15.2)

0(0)

	0.023c*	
b: Chi-square test; c:Mann Whitney test; *:significant at P<0.05

Discussion

In our study, the communication group showed better patient satisfaction. More importantly, the communication group showed more significant improvement in pain and lumbar function in the early postoperative period, indicating that the communication group had better early outcomes. The results prompt that patient participation in preoperative and postoperative communication can promote patient recovery and improve treatment satisfaction.

Early recovery after lumbar disc herniation surgery is one of the critical concerns of orthopedic physicians. In order to promote the early healing of patients, the traditional posterior approach of open surgery has evolved into minimally invasive treatment. With the advancement of technology, the indications have gradually expanded, becoming a reliable treatment method for spinal diseases [10]. Many scholars are also exploring which minimally invasive surgery is more advantageous, but it is still controversial [9, 11, 12]. In addition to surgical procedures, various methods can help patients recover early, including successful surgery, early functional exercise, and good compliance. We believe that patients’ accurate understanding of the surgical process and intraoperative participation in communication are beneficial for early recovery. Within one month after surgery, the communication group demonstrated better lumbar spine function.

Postoperative pain often not only affects patients’ recovery but may also affect their physical and mental health. Reasonable pain control is crucial for rapid recovery [13, 14]. Medication to relieve pain is the most commonly used method, but there is a risk of gastrointestinal reactions, increased cardiovascular and renal adverse events, addiction, and even death [15–17]. Effective doctor-patient communication has a therapeutic effect, such as drug treatment, which can effectively control pain and improve the patient’s psychological state [18, 19]. McDonald [20] conducted effective communication interventions on patients undergoing total knee arthroplasty before surgery, and the results showed that the communication group had significantly better early postoperative pain relief than the non-communication group. Our research suggests that the communication group showed better pain control while we did not use additional analgesics. This may be due to preoperative observation of the surgical process and intraoperative procedures, good communication, and understanding of the surgery, which can help alleviate patient anxiety and alleviate subjective feelings of pain.

The PEID procedure can reduce injury, but there are still reports of surgical complications such as nerve root injury, postoperative sensory dullness, dural tear, hematoma, infection, and recurrence [21–25]. A meta-analysis by Jitpakdee et al. [2] found that the overall incidence of complications in PEID is about 11%, and there is a negative correlation between surgeon proficiency in surgery and surgical complications. Ma et al. [25] conducted a 2-year follow-up study on 45 cases of open fenestration discectomy (OFD) and 46 cases of PEID treatment for single-segment giant lumbar disc herniation. The results showed that the complications of PEID were comparable to OFD, and there was no difference in recurrence rates between the two groups. Our study’s overall incidence of complications was 4.35%, with 2.7% in the communication group and 6.1% in the non-communication group, which was lower than 11% reported. There was no recurrence during the follow-up period, which may be related to our surgeon’s proficiency in the surgical procedure and the shorter follow-up time. Moreover, it was found through comparison that communicating with patients during surgery did not result in increased complications due to distraction, reflecting the safety of intraoperative communication in surgical procedures.

In the United States, patient satisfaction is one of the healthcare system’s reference indicators, which positively impacts patients’ adherence to treatment plans and follow-up [26, 27]. Doctor-patient communication, preoperative expectations, and expectations are positively correlated with better functional recovery and high satisfaction [28–30]. Etier et al.‘s [31] survey of 353 spinal surgery patients showed that sufficient time spent with them impacted patient satisfaction. Ruan et al.‘s [32]research suggests that patient engagement during surgery effectively improves patient compliance and early functional recovery. Intraoperative participation enables patients to understand the surgical process, build good doctor-patient trust, and enhance treatment satisfaction. The result is consistent with our research. We allow patients to watch surgical videos before surgery, understand the process and purpose of the surgery, participate in intraoperative surgical communication, and intuitively see the situation of intervertebral disc herniation and compression. It is beneficial for patients to set appropriate expected therapeutic effects while answer the patient ‘s intraoperative questions, ultimately improving their treatment satisfaction.

Obviously, This mode does not require additional drug use and economic costs for watching surgical videos before surgery to understand the surgical process and watching screens during surgery to participate in communication, nor does it increase hospitalization time, which can improve patients’ postoperative recovery and treatment satisfaction.

However, that is a concern, intraoperative communication may distract the surgeon’s attention, which increases surgical complications. In addition, answering additional questions during surgery increases surgical time. Yet, our study had no increased complications or serious adverse events.

Limitation

There are some limitations to this study. Firstly, retrospective research of single-center is not randomized, limiting the sample size that can be included in the study, and the results may be biased. Secondly, we only followed with interest the impact of patient participation on the postoperative outcome of PEID surgery, while PTED and Unilateral Biportal Endoscopic (UBE) are also commonly used surgical procedures in spinal orthopedics, which requires further research.Further studies will be carried out on the applicability of this protocol in other endoscopic procedures. Finally, further research is needed to determine whether intraoperative communication can cause distraction and adversely affect the surgeon.

Conclusion

When performing PEID surgery, preoperative patient viewing of surgical videos and intraoperative communication can alleviate pain, accelerate patient functional recovery, improve symptoms, and increase patient satisfaction. We need to do more work to develop this new model.

Acknowledgements

We sincerely thank all of the participants for helping to make this study possible.

Author contributions

W.L.wrote the main manuscript text and prepared tables. L.L. collected and analyzed the data. Z.P. and E.G.designed this research and revised the manuscript. All authors reviewed the manuscript.

Funding

No funding.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

In accordance with the Declaration of Helsinki, approval from the Medical Ethics Committee of Chuzhou Chinese and Western Medicine Hospital was obtained for this study(2023-16). All patients participating in the study have signed an informed consent form.

Consent for publication

All authors have read and agreed to the published version of the manuscript.

Competing interests

The authors declare no competing interests.

Abbreviations

PEID Percutaneous Endoscopic Interlaminar Discectomy

LDH Lumbar disc herniation

PELD Percutaneous Endoscopic Lumbar Discectomy

PTED Percutaneous Transforaminal Endoscopic Discectomy

CT Computer tomography

MRI Magnetic resonance imaging

VAS Visual Analogue Scale

JOA Japanese Orthopaedic Association

OFD Open fenestration discectomy

UBE Unilateral Biportal Endoscopic

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Wang-xin Liu and Lei Liu have contributed equally to this work.
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