Study Design. An updated Cochrane Review.
Objectives. To assess the effects of surgical interventions for the treatment of lumbar disc prolapse.
Summary of Background Data. Disc prolapse accounts for 5% of low back disorders yet is one of the most common reasons for surgery. There is still little scientific evidence supporting some interventions.
Methods. Use of standard Cochrane review methods to analyze all randomized controlled trials published up to January 1, 2007.
Results. Forty randomized controlled trials (RCTs) and 2 quasi-RCTs were identified. Many of the early trials were of some form of chemonucleolysis, whereas the majority of the later studies either compared different techniques of discectomy or the use of some form of membrane to reduce epidural scarring. Four trials directly compared discectomy with conservative management, and these give suggestive rather than conclusive results. However, other trials show that discectomy produces better clinical outcomes than chemonucleolysis, and that in turn is better than placebo. Microdiscectomy gives broadly comparable results to standard discectomy. Recent trials of an interposition gel covering the dura (5 trials) and of fat (4 trials) show that they can reduce scar formation, although there is limited evidence about the effect on clinical outcomes. There is insufficient evidence on other percutaneous discectomy techniques to draw firm conclusions. Three small RCTs of laser discectomy do not provide conclusive evidence on its efficacy. There are no published RCTs of coblation therapy or transforaminal endoscopic discectomy.
Conclusion. Surgical discectomy for carefully selected patients with sciatica due to lumbar disc prolapse provides faster relief from the acute attack than conservative management, although any positive or negative effects on the lifetime natural history of the underlying disc disease are still unclear. The evidence for other minimally invasive techniques remains unclear except for chemonucleolysis using chymopapain, which is no longer widely available.
The 2007 Cochrane Review presents an analysis of outcome data from 40 randomized and 2 quasi-randomized controlled trials of surgical interventions used in the treatment of lumbar disc prolapse. Seventeen of the trials have been published in the last 8 years. Meta-analysis allows conclusions to be drawn on the effectiveness of some interventions.
From the Spinal Unit, Royal Infirmary of Edinburgh and the University of Edinburgh, Edinburgh, Scotland.
Supported by the Medical Research Council, UK.
This paper is based on Gibson JNA, Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database of Systematic Reviews 2007, Issue 2, a Cochrane Review published in The Cochrane Library 2007, Issue 2 (www.thecochranelibrary.com). Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and the Cochrane Library should be consulted for the most recent version of the review.
The device(s)/drug(s) is/are FDA-approved or approved by corresponding national agency for this indication.
Federal funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.
Address correspondence and reprint requests to J. N. Alastair Gibson, MD, FRCS, Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SU, UK; E-mail: firstname.lastname@example.org.