Comparison of Clinical Outcomes and Biochemical Markers Following Tubular Microscopic Discectomy Versus Full Endoscopic Discectomy for Lumbar Disc Herniation: A Prospective Randomized Controlled Trial

Abstract

Study Design

Prospective randomized controlled trial.

Objective

To compare clinical outcomes and biochemical markers in patients undergoing tubular microscopic discectomy (TMD) versus full endoscopic discectomy (FED).

Methods

This prospective randomized controlled trial was conducted at a tertiary spine center between February 2022 and December 2023. A total of 209 patients with symptomatic lumbar disc herniation were randomized using a sealed opaque envelope allocation method to undergo either FED or TMD. For subgroup analysis, FED cases were stratified into interlaminar (IL-FED) and transforaminal (TF-FED) approaches. Clinical outcomes were systematically evaluated using the Visual Analog Scale (VAS), Oswestry Disability Index (ODI) and modified MacNab criteria preoperatively, immediately postoperatively, and at 3-, 6- and 12-month follow-up intervals. Biochemical markers, including C-reactive protein (CRP) and creatine phosphokinase-MM (CPK-MM) were measured preoperatively and at 24 hours postoperatively to assess muscle injury and inflammatory response. Secondary outcomes included perioperative complications and time to return to work.

Results

Both groups demonstrated statistically significant improvement in VAS and ODI scores across all follow-up intervals. Although baseline VAS differed statistically between groups, the magnitude of this difference was not clinically meaningful and did not influence postoperative outcomes. The FED group demonstrated significantly better ODI and MacNab scores, reflecting improved functional recovery and patient satisfaction. Postoperative CRP and CPK-MM levels were significantly lower in the FED group, indicating reduced paraspinal muscle injury and systemic inflammatory response.

Conclusion

Both TMD and FED are effective treatment modalities. However, FED is associated with reduced muscle injury and accelerated postoperative recovery.

Keywords

lumbar disc herniation endoscopic discectomy tubular microdiscectomy minimally invasive spine surgery CPK-MM

Introduction

Lumbar disc herniation is one of the most common causes of radiculopathy and low back pain, often leading to significant functional impairment and reduced quality of life.^1,2 When conservative treatment fails, surgical decompression is indicated to relieve neural compression and restore function. Conventional open lumbar microdiscectomy, popularized by Yasargil and Caspar, has long been considered the gold standard surgical procedure, demonstrating high success rates and durable outcomes.^3,4 However, open approaches are associated with paraspinal muscle injury, postoperative pain, and longer recovery periods.

Over the past three decades, advances in minimally invasive spine surgery (MISS) have led to the development of techniques aimed at minimizing tissue trauma while maintaining effective neural decompression. Tubular microscopic discectomy (TMD), performed using muscle-splitting dilators and tubular retractors under microscopic visualization, preserves midline structures and reduces muscle dissection compared with open surgery.⁵ Clinical studies have shown that tubular techniques can achieve outcomes comparable to conventional microdiscectomy with reduced postoperative pain, blood loss, and hospital stay.⁶

Full endoscopic discectomy (FED) represents a further evolution of MISS, utilizing a working-channel endoscope introduced via transforaminal or interlaminar approaches. This technique allows decompression under continuous irrigation with minimal disruption of paraspinal musculature, ligaments, and bony structures.⁷ Improvements in optics, instrumentation, and surgical navigation have expanded the indications for FED, making it an increasingly popular alternative for lumbar disc herniation. Several studies have reported favorable clinical outcomes, faster recovery, and earlier return to work following endoscopic procedures.⁸ Nevertheless, FED is technically demanding and associated with a steep learning curve.⁹

Muscle injury resulting from surgical exposure is a key determinant of postoperative pain and recovery. Biochemical markers such as creatine phosphokinase-MM (CPK-MM) and C-reactive protein (CRP) are commonly used to quantify muscle damage and systemic inflammatory response following spine surgery.^10-12 Elevated postoperative levels of these markers have been correlated with the extent of tissue trauma and surgical invasiveness.¹³ Despite the theoretical advantages of minimally invasive techniques, limited prospective data exist comparing biochemical indicators of muscle injury between different MISS approaches.

Although numerous studies have compared minimally invasive techniques with open microdiscectomy, direct comparisons between Tubular microscopic discectomy (TMD) and full endoscopic discectomy remain scarce, particularly in the form of randomized controlled trials. Moreover, few investigations have evaluated both clinical outcomes and objective biochemical markers within the same study population.

Therefore, the present prospective randomized controlled trial was conducted to compare clinical outcomes and biochemical markers of muscle injury in patients with lumbar disc herniation undergoing Tubular microscopic discectomy (TMD) versus full endoscopic discectomy. We hypothesized that full endoscopic discectomy would result in reduced muscle damage, lower inflammatory response, and faster functional recovery while achieving comparable pain relief and disability improvement.

Material and Methods

Reporting and Registration

The study was conducted in accordance with CONSORT guidelines; however, prospective trial registration was not performed due to administrative limitations. Although prospective trial registration was not performed, all primary and secondary outcomes reported in the manuscript were predefined in the study protocol before patient enrollment and data collection.

The patient flow through the study is illustrated in Figure 1.

Figure 1.

CONSORT flow diagram illustrating patient enrollment, randomization, allocation, follow-up, and analysis

Study Design

This prospective randomized controlled trial was conducted at a tertiary spine care center after obtaining Institutional Ethics Committee approval (IEC No: VK010722). Written informed consent was obtained from all participants prior to enrollment.

Randomization

Randomization was performed using sequentially numbered sealed opaque envelopes without block randomization. As a result, chance imbalance occurred during allocation, resulting in 116 patients being assigned to the FED group and 93 to the TMD group. No post-randomization exclusions occurred prior to treatment allocation.

Inclusion Criteria

● Age >18 years

● Clinical symptoms of lumbar disc herniation confirmed by MRI.

● Failure of adequate conservative management.

● Willingness to participate and comply with follow-up protocol.

Exclusion Criteria

● Revision spine surgery.

● Requirement for an open surgical procedure.

● Requirement of fusion or instrumentation procedures.

● Presence of spinal tumors or infection.

● Patients unwilling to undergo randomization.

Surgical Technique

All procedures were performed by a single experienced spine surgeon proficient in both techniques, thereby minimizing the influence of the learning curve on surgical outcomes.

In the FED group, surgery was performed using a 4.1-mm working-channel endoscope via interlaminar or transforaminal approaches depending on the level and pathological characteristics. Continuous saline irrigation was utilized, and decompression was achieved with minimal disruption of soft tissues and bony structures (Figures 2-4).

Figure 2.

Full endoscopic discectomy setup demonstrating patient positioning, endoscopic system, and working channel arrangement

Figure 3.

Percutaneous insertion of the working cannula under fluoroscopic guidance during full endoscopic discectomy

Figure 4.

Endoscopic intraoperative view showing herniated disc fragment and adjacent neural structures during decompression

In the TMD group, surgery was performed using a standard tubular retractor system under microscopic visualization. Sequential dilation was followed by discectomy through a minimally invasive tubular corridor, preserving surrounding musculature and posterior structures (Figure 5).

Figure 5.

Tubular microscopic discectomy technique demonstrating sequential dilation and tubular retractor placement

Outcome Measures

Clinical outcomes were assessed using validated scoring systems.

● Visual Analog Scale (VAS) for pain assessment

● Oswestry Disability Index (ODI) for functional disability

● Modified MacNab criteria for overall patient satisfaction

Assessments were performed preoperatively, immediately postoperatively, and at 3-, 6- and 12-month follow-up intervals.

Biochemical markers (CRP and CPK-MM) were measured preoperatively and at 24 hours postoperatively to objectively quantify muscle injury and inflammatory response.

Secondary outcomes included perioperative complications, and time to return to work.

Blinding

Outcome assessment was performed by an independent assessor who was blinded to group allocation. Patients were not blinded due to the inherent nature of the surgical interventions (Figures 6 and 7).

Figure 6.

Preoperative and postoperative MRI images following full endoscopic discectomy. (A) Preoperative sagittal view showing disc herniation (B) Postoperative sagittal view showing adequate decompression (C) Preoperative axial view (D) Postoperative axial view

Figure 7.

Preoperative and postoperative MRI images following tubular microscopic discectomy. (A) Preoperative sagittal view showing disc herniation (B) Postoperative sagittal view showing decompression (C) Preoperative axial view (D) Postoperative axial view

Statistical Analysis

Data were analyzed using SPSS version 29. Continuous variables were expressed as mean ± standard deviation and compared using unpaired t-tests after confirming normal distribution. Categorical variables were analyzed using chi-square tests. A p-value <0.05 was considered statistically significant.

Adjusted analysis using baseline VAS as a covariate (ANCOVA) was performed and did not alter the primary outcomes. Additionally, a post hoc power analysis demonstrated that the study had adequate statistical power (>80%) to detect clinically meaningful differences between the groups.

Results

A total of 209 patients were randomized. 116 patients were allocated to the FED group and 93 to the TMD group. Four patients in the FED group and three patients in the TMD group were lost to follow-up, leaving 112 and 90 patients, respectively, for final analysis (Table1). Of the 112 patients in the FED group, 86 underwent interlaminar FED (IL-FED) and 26 underwent transforaminal FED (TF-FED).

Table 1.

Demographic Data

	FED	TMD	P value
Age	46.69 +/- 12.45	47.91 +/- 14.11	0.52
Sex	Male - 80, Female - 32	Male - 70, Female - 20	0.39
Comorbidities	43	41	0.38
L3-L4, n	8	7
L4-L5, n	52	42
L5-S1, n	37	35
Two-level, n	15	6
Single-level, n	97	84	0.44

A sensitivity analysis restricted to IL-FED cases (n = 86) was performed to allow a more comparable analysis with the TMD group. The results remained consistent with the primary analysis, with no significant differences in VAS between IL-FED and TMD, whereas ODI, MacNab scores, CRP, and CPK-MM continued to favor IL-FED, consistent with the primary analysis. (Supplementary Table 2).

Demographic characteristics, including age, sex, comorbidities, and distribution of operated levels, are presented in Table 1. Majority of the patients underwent single level discectomy, in the FED group, 97 out of 112 patients underwent single level discectomy and 15 patients underwent discectomy at two levels. In the TMD group, 84 out of 90 patients underwent single level discectomy and 6 patients underwent discectomy at two levels. (Table1).

To evaluate the potential influence of two-level procedures on study outcomes, a sensitivity analysis restricted to single-level cases was performed (Supplementary Table S3). The findings remained consistent with the primary analysis, with FED demonstrating superior functional outcomes, lower postoperative CRP and CPK-MM levels, and earlier return-to-work times. No material change in the overall study conclusions was observed after exclusion of two-level cases.

VAS, ODI, and MacNab scores were assessed for both the groups and the values are listed in Tables 2-4. While both the groups showed similar improvements in pain (VAS), the FED group achieved a statistically significant better ODI score and MacNab score, indicating a higher level of patient satisfaction and functional improvement. Table 5 reveals that in the postoperative period, the mean CRP and CPK-MM levels were significantly lower in the FED group as compared to the TMD group and this difference was statistically significant. Patients in the FED group returned to work significantly earlier (in weeks) as compared to the TMD group which was statistically significant as depicted in Table 6.

Table 2.

VAS Score

VAS	FED		TMD		P value
VAS	Mean	SD	Mean	SD	P value
Pre-operative	7.82	0.73	6.86	0.91	<0.0001
Post-operative	3.08	0.78	3.31	0.99	0.12
Follow up 1	1.13	0.78	1.18	0.70	0.70
Follow up 2	0.54	0.58	0.57	0.50	0.76
Follow up 3	0.39	0.53	0.3	0.47	0.32

Table 3.

ODI Score

ODI	FED		TMD		P value
ODI	Mean	SD	Mean	SD	P value
Pre-operative	32.03	2.91	32.68	1.99	0.17
Post-operative	20.58	4.27	22.71	2.12	0.001
Follow up 1	14.48	4.04	17.32	2.26	<0.0001
Follow up 2	9.91	3.17	11.96	1.89	0.0001
Follow up 3	6.3	2.69	8.8	1.88	<0.0001

Table 4.

MacNab Score

MacNab	FED	%	TMD	%
Fair	5	4.46	20	22.22
Good	50	44.64	46	51.11
Excellent	57	50.89	24	26.67
Total	112	100	90	100
Mean +/- SD	3.46+/- 0.58		3.04+/-0.7
P value	0.0002

Table 5.

CPK-MM and CRP Levels

Parameter	FED		TMD		P value
	Mean +/- SD		Mean +/- SD		P value
	Pre-op	Post-op	Pre-op	Post-op	Pre-op	Post-op
CRP (mg/l)	2.87 +/- 3.70	13.04 +/- 17.95	2.17+/- 1.39	27.15 +/- 18.98	0.21	<0.0001
CPK-MM (ng/ml)	1.64 +/- 1.6	3.009 +/- 3.11	1.82 +/- 1.13	8.77 +/- 6.45	0.50	<0.0001

Table 6.

Time Taken to Return to Work (in Weeks)

Return to work (in weeks)	FED		TMD
Return to work (in weeks)	No. of patients	Percentage	No. of patients	Percentage
Four	60	53.57	20	22.22
Five	10	8.92	6	6.66
Six	35	31.25	37	41.11
Seven	3	2.67	4	4.44
Eight	4	3.57	23	25.55
Total	112	100	90	100
Mean +/- SD	4.93 +/-0.89		6.0 +/-1.51
P – value	<0.0001

Because baseline VAS scores differed significantly between groups, an ANCOVA adjusted for baseline VAS was performed. The adjusted analysis yielded results consistent with the primary analysis, indicating that the baseline imbalance did not materially affect study conclusions.

Among surgery related complications, two patients in the FED group and four in the TMD group had a dural tear. Neurological complications were noted in two patients in the FED group and three in the TMD group. (Table 7).

Table 7.

Complications, Recurrence, and Reoperation

Outcome	FED (n = 112)	TMD (n = 90)	p value
Dural tear	2	4	Descriptive
Neurological complication	2	3	Descriptive
Recurrence requiring revision surgery	5 (4.5%)	2 (2.2%)	Fisher exact test 0.47

Revision surgery for recurrent symptoms was required in 5 of 112 patients (4.5%) in the FED group and 2 of 90 patients (2.2%) in the TMD group. Fisher’s exact test demonstrated no statistically significant difference between the groups (p = 0.47).

Regarding the timing of recurrence, three FED recurrences occurred within the first 6 months following surgery, while two occurred between 6 and 12 months. Both recurrence events in the TMD group occurred within the first 6 months of follow-up. (Table 7).

Discussion

Advances in minimally invasive spine surgery have led to the widespread adoption of both tubular microscopic discectomy and full endoscopic discectomy for the treatment of lumbar disc herniation. Numerous studies have compared comparing open spine surgery with minimally invasive techniques which has shown improved VAS and ODI scores and shorter hospital stays in the minimally invasive group.^14-16 However, direct comparisons between FED and TMD remain limited when it comes to comparing the FED and the TMD groups.

In our study, both FED and TMD groups showed similar improvements in pain, but the FED group achieved significantly better ODI scores, MacNab score. This may be attributed to the less invasive nature of FED, potentially leading to faster pain relief and improved quality of life.

The inclusion of both interlaminar and transforaminal FED approaches introduces heterogeneity due to differences in anatomical access and muscle disruption. To address this, a sensitivity analysis restricted to IL-FED cases was performed, which demonstrated findings consistent with the primary analysis. This strengthens the validity of our conclusions. However, the inclusion of TF cases remains a potential source of residual confounding.

Although the FED group contained a greater number of two-level procedures (15 versus 6), sensitivity analysis restricted to single-level cases demonstrated findings consistent with the primary analysis. This suggests that the observed advantages associated with FED were not primarily driven by the unequal distribution of two-level procedures and supports the robustness of the study conclusions.

Kotheeranurak et al in their study compared Full endoscopic (FE) decompression with tubular based microscopic decompression in patients with single level lumbar canal stenosis.¹⁷ They demonstrated that the FE decompression group showed a statistically significant improvement in the mean VAS score for back pain after surgery.¹⁷ No significant difference was observed in the VAS score for leg pain, European quality of life – 5 Dimensions (EQ–5D) score, walking time, modified MacNab criteria, operative time, radiation exposure, revision rate and complication rate between the two groups. They concluded that full endoscopic decompression is an effective alternative treatment for patients with lumbar canal stenosis and it offers advantages in terms of less invasive surgery, less blood loss and shorter length of hospital stay.¹⁷

Shi et al in their paper concluded that percutaneous endoscopic lumbar discectomy (PELD) as compared to micro-endoscopic discectomy (MED) achieved better outcomes with respect to the length of the incision, blood loss, post-operative in-bed time, post-operative hospital stay and VAS-back pain after surgery.¹⁸

Liu et al in their study compared percutaneous transforaminal endoscopic discectomy (PTED) and microscopic assisted tubular discectomy (MTD) for lumbar disc herniation and concluded that PTED has the advantages of shorter incision length, less intraoperative blood loss, shorter hospital stay, low incidence of back pain, fewer complications and early recovery.¹⁹

Muscle trauma following various lumbar spinal procedures is assessed through the quantification of the enzyme CPK-MM. This enzyme is typically released into the blood stream as a response to muscle damage or injury incurred during surgery.²⁰ Serum CPK-MM levels tend to peak approximately one day after the procedure, indicating the maximum release of the enzyme in response to the surgical intervention.²⁰ This elevation reflects the body’s natural response to repair and regenerate the damaged muscle tissue. Thus, monitoring the CPK-MM levels can provide valuable insight into the extent of muscle trauma and the patient’s recovery trajectory. Our study demonstrated significantly lower CPK-MM and CRP levels in the FED group as compared to the TMD group, indicating less muscle damage and inflammatory response associated with FED. This aligns with the minimally invasive nature of FED, which utilizes smaller incisions and potentially less muscle retraction, leading to faster recovery and shorter hospital stays as observed in our study. Patients in the FED group exhibited a quicker return to work as compared to the TMD group. Fujii et al in their study reported that the mean duration to return to work after surgery among 6 medical doctors was 5.8 days.²¹

Shahi et al in their paper concluded that more than 80% of the patients return to work on an average 25 days after a transforaminal lumbar interbody fusion (TLIF), 14 days after spinal decompression surgery and 11 days after a microdiscectomy.²²

Muthu et al in their paper reported that the average duration for return to work in endoscopic discectomy (ED) and microdiscectomy (MD) was 4.75 and 6.19 weeks respectively.²³ In our study also, the mean duration for return to work after FED was 4.93 weeks and after TMD was 6 weeks.

Merits of our study include its study design, as it is a randomized controlled trial with a good sample size and the use of biochemical markers to quantify muscle damage. Also, both surgical techniques were performed by the same lead surgeon, reducing inter-surgeon variability.

Recurrence and reoperation were formally evaluated as safety outcomes. Revision surgery was required in 5 FED patients (4.5%) and 2 TMD patients (2.2%). Although numerically higher in FED, this difference was not statistically significant (Fisher exact p = 0.47). Given the small number of recurrence events, this finding should not be interpreted as evidence that FED inherently carries a higher recurrence risk. Potential explanations include differences in disc morphology, completeness of decompression, approach selection, patient-related factors, or chance. Larger multicenter studies are required to determine whether recurrence differs meaningfully between techniques.

Several limitations should be acknowledged.

• This was a single-center, single-surgeon study, which limits external validity and generalizability.

• BMI was not prospectively recorded as a predefined variable also complete and reliable BMI data were unavailable therefore could not be incorporated into adjusted analyses. Because BMI can influence surgical difficulty, operative time, inflammation, and muscle injury markers, this is an important limitation.

• Follow-up was limited to 12 months. Longer follow-up is required to evaluate durability, late recurrence, and reoperation.

The present study is strengthened by its randomized controlled design, inclusion of objective biochemical markers of muscle injury, blinded outcome assessment, and sensitivity analyses addressing both FED approach heterogeneity and the unequal distribution of two-level procedures. Collectively, these findings provide robust evidence supporting the muscle-preserving advantages of FED while demonstrating comparable pain relief to TMD.

Conclusion

Both TMD and FED are effective treatment options for lumbar disc herniation. However, FED offers several potential advantages over TMD in terms of reduced muscle injury, faster recovery, potentially improved functional outcomes and early return to work. Further multicenter studies with larger sample sizes and longer follow-up are required to validate these findings and better define the role of FED in the surgical management of lumbar disc herniation.

Supplemental Material

Supplemental material - Comparison of Clinical Outcomes and Biochemical Markers Following Tubular Microscopic Discectomy Versus Full Endoscopic Discectomy for Lumbar Disc Herniation: A Prospective Randomized Controlled Trial

Supplemental material for Comparison of Clinical Outcomes and Biochemical Markers Following Tubular Microscopic Discectomy Versus Full Endoscopic Discectomy for Lumbar Disc Herniation: A Prospective Randomized Controlled Trial by Ayush Sharma, Ajit Rampure, Shubham Kadam, Nandan Marathe, Sourav Lal Das in Global Spine Journal.

Supplemental Material

Supplemental material - Comparison of Clinical Outcomes and Biochemical Markers Following Tubular Microscopic Discectomy Versus Full Endoscopic Discectomy for Lumbar Disc Herniation: A Prospective Randomized Controlled Trial

Footnotes

ORCID iDs

Ajit Rampure

Shubham Kadam

Nandan Marathe

Ethical Considerations

This study was approved by the Institutional Ethics Committee. Approval number- IEC No: VK010722. Name- Bharatratna Dr. Babasaheb Ambedkar Memorial Hospital Ethics committee. Institution- Dr Babasaheb Ambedkar Memorial Hospital, Mumbai, India.

Consent for Publication

Appropriate written informed consent has been taken from all the patients for inclusion in the study and publication process.

Author Contributions

Conceptualization: Ayush Sharma.

Methodology: Ajit Rampure.

Data Collection and Analysis: Sourav Lal Das, Nandan Marathe.

Draft Writing: Shubham Kadam.

Review & Editing: Ajit Rampure, Shubham Kadam.

Supervision: Ayush Sharma.

All authors approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.*

Supplemental Material

Supplemental material for this article is available online.

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