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Review
. 2007 Apr 18;2007(2):CD001350.
doi: 10.1002/14651858.CD001350.pub4.

Surgical Interventions for Lumbar Disc Prolapse

Affiliations
Free PMC article
Review

Surgical Interventions for Lumbar Disc Prolapse

J N A Gibson et al. Cochrane Database Syst Rev. .
Free PMC article

Abstract

Background: Disc prolapse accounts for five percent of low-back disorders but is one of the most common reasons for surgery.

Objectives: The objective of this review was to assess the effects of surgical interventions for the treatment of lumbar disc prolapse.

Search strategy: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, Spine and abstracts of the main spine society meetings within the last five years. We also checked the reference lists of each retrieved articles and corresponded with experts. All data found up to 1 January 2007 are included.

Selection criteria: Randomized trials (RCT) and quasi-randomized trials (QRCT) of the surgical management of lumbar disc prolapse.

Data collection and analysis: Two review authors assessed trial quality and extracted data from published papers. Additional information was sought from the authors if necessary.

Main results: Forty RCTs and two QRCTs were identified, including 17 new trials since the first edition of this review in 1999. 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. Despite the critical importance of knowing whether surgery is beneficial for disc prolapse, only four trials have 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 inter-position gel covering the dura (five trials) and of fat (four trials) show that they can reduce scar formation, though 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 trans-foraminal endoscopic discectomy.

Authors' conclusions: 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. Microdiscectomy gives broadly comparable results to open discectomy. The evidence on other minimally invasive techniques remains unclear (with the exception of chemonucleolysis using chymopapain, which is no longer widely available).

Conflict of interest statement

None known

Figures

1.1
1.1. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 1 No success at 6 wks ‐ patient rated.
1.2
1.2. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 2 No success at 6 mths ‐ patient rated.
1.3
1.3. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 3 No success at 1 yr plus ‐ patient rated.
1.4
1.4. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 4 No success at 2 yrs ‐ patient rated.
1.5
1.5. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 5 No success at 10 yrs ‐ patient rated.
1.6
1.6. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 6 No success at 6 wks ‐ surgeon rated.
1.7
1.7. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 7 No success at 3 mths ‐ surgeon rated.
1.8
1.8. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 8 No success at 6 mths ‐ surgeon rated.
1.9
1.9. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 9 No success at 1 yr ‐ surgeon rated.
1.10
1.10. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 10 No success at 2yrs ‐ surgeon rated.
1.11
1.11. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 11 No success at 10 yrs ‐ surgeon rated.
1.12
1.12. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 12 No success at 3 mths ‐ independent observer rated.
1.13
1.13. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 13 No success at 6 mths ‐ independent observer rated.
1.14
1.14. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 14 No success at 3‐12 mths ‐ independent observer rated.
1.15
1.15. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 15 2nd procedure needed within 1 yr.
1.16
1.16. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 16 2nd procedure needed 6‐24mths.
1.17
1.17. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 17 2nd procedure needed within 10 yrs.
1.18
1.18. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 18 Code break within 6 mths.
1.19
1.19. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 19 No improvement in back pain at 4 to 6 weeks.
1.20
1.20. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 20 No improvement in sciatica at 42 to 90 days.
2.1
2.1. Analysis
Comparison 2 DISCECTOMY V. CHYMOPAPAIN, Outcome 1 Condition unchanged/worse at 1 yr ‐ patient rated.
2.2
2.2. Analysis
Comparison 2 DISCECTOMY V. CHYMOPAPAIN, Outcome 2 Poor outcome obtained at 1 yr ‐ surgeon rated.
2.3
2.3. Analysis
Comparison 2 DISCECTOMY V. CHYMOPAPAIN, Outcome 3 Mediocre/bad result at 2 yrs ‐ surgeon rated.
2.4
2.4. Analysis
Comparison 2 DISCECTOMY V. CHYMOPAPAIN, Outcome 4 No success at 2 yrs ‐ independent observer rated.
2.5
2.5. Analysis
Comparison 2 DISCECTOMY V. CHYMOPAPAIN, Outcome 5 2nd procedure needed within 1 yr.
2.6
2.6. Analysis
Comparison 2 DISCECTOMY V. CHYMOPAPAIN, Outcome 6 2nd procedure needed within 2 yrs.
2.7
2.7. Analysis
Comparison 2 DISCECTOMY V. CHYMOPAPAIN, Outcome 7 2nd procedure within 1‐2 years.
3.1
3.1. Analysis
Comparison 3 DISCECTOMY V. CHYMOPAPAIN PLUS DISCECTOMY IF NECESSARY, Outcome 1 Unsatisfactory at 1 yr without second surgery ‐ patient rated.
3.2
3.2. Analysis
Comparison 3 DISCECTOMY V. CHYMOPAPAIN PLUS DISCECTOMY IF NECESSARY, Outcome 2 Unsatisfactory at 1 year after all treatments ‐ patient rated.
3.3
3.3. Analysis
Comparison 3 DISCECTOMY V. CHYMOPAPAIN PLUS DISCECTOMY IF NECESSARY, Outcome 3 Unsatisfactory at 1 year without second surgery ‐ physician rated.
3.4
3.4. Analysis
Comparison 3 DISCECTOMY V. CHYMOPAPAIN PLUS DISCECTOMY IF NECESSARY, Outcome 4 2nd procedure needed within 1 yr.
4.1
4.1. Analysis
Comparison 4 AUTOMATED PERCUTANEOUS DISCECTOMY V. CHYMOPAPAIN, Outcome 1 No success at 1 yr ‐ patient rated.
4.2
4.2. Analysis
Comparison 4 AUTOMATED PERCUTANEOUS DISCECTOMY V. CHYMOPAPAIN, Outcome 2 2nd procedure needed within 1 yr.
5.1
5.1. Analysis
Comparison 5 COLLAGENASE V. CHYMOPAPAIN, Outcome 1 Fair or poor outcome at 1 yr ‐ surgeon rated.
5.2
5.2. Analysis
Comparison 5 COLLAGENASE V. CHYMOPAPAIN, Outcome 2 2nd treatment needed within 3 yrs.
5.3
5.3. Analysis
Comparison 5 COLLAGENASE V. CHYMOPAPAIN, Outcome 3 Fair or poor outcome at 5 years.
6.1
6.1. Analysis
Comparison 6 STEROID V. CHYMOPAPAIN, Outcome 1 Failure / No improvement ‐ independent observer rated.
6.2
6.2. Analysis
Comparison 6 STEROID V. CHYMOPAPAIN, Outcome 2 2nd procedure needed between 6‐24 mths.
7.1
7.1. Analysis
Comparison 7 LOW‐DOSE V. STANDARD DOSE CHYMOPAPAIN, Outcome 1 No success at 30 days ‐ patient rated.
7.2
7.2. Analysis
Comparison 7 LOW‐DOSE V. STANDARD DOSE CHYMOPAPAIN, Outcome 2 No success at 1 yr ‐ surgeon rated.
8.1
8.1. Analysis
Comparison 8 COLLAGENASE V. PLACEBO, Outcome 1 Poor result obtained at 17 mths ‐ patient rated.
9.1
9.1. Analysis
Comparison 9 COLLAGENASE INTRAPROTRUSION V. INTRADISK, Outcome 1 No effect.
10.1
10.1. Analysis
Comparison 10 MICRO. V. STANDARD DISCECTOMY, Outcome 1 Condition unchanged / worse at 1 yr ‐ patient rated.
10.2
10.2. Analysis
Comparison 10 MICRO. V. STANDARD DISCECTOMY, Outcome 2 Poor outcome 12‐18 mths ‐ independent assessor rated.
11.1
11.1. Analysis
Comparison 11 DISCECTOMY V. CONSERVATIVE ± DISCECTOMY, Outcome 1 Poor/bad result at 1 yr ‐ surgeon rated.
11.2
11.2. Analysis
Comparison 11 DISCECTOMY V. CONSERVATIVE ± DISCECTOMY, Outcome 2 Poor/bad result at 4 yrs ‐ surgeon rated.
11.3
11.3. Analysis
Comparison 11 DISCECTOMY V. CONSERVATIVE ± DISCECTOMY, Outcome 3 Poor/bad result at 10 yrs ‐ surgeon rated.
11.4
11.4. Analysis
Comparison 11 DISCECTOMY V. CONSERVATIVE ± DISCECTOMY, Outcome 4 Oswestry disability index.
12.1
12.1. Analysis
Comparison 12 PERCUTANEOUS ENDOSCOPIC DISCECTOMY (ANY TYPE) V. MICRODISCECTOMY, Outcome 1 Poor result at 6 mos to 2 yrs ‐ pt rated.
12.2
12.2. Analysis
Comparison 12 PERCUTANEOUS ENDOSCOPIC DISCECTOMY (ANY TYPE) V. MICRODISCECTOMY, Outcome 2 Failure at 6 mths ‐ Independent observer rated (Automated alone).
12.3
12.3. Analysis
Comparison 12 PERCUTANEOUS ENDOSCOPIC DISCECTOMY (ANY TYPE) V. MICRODISCECTOMY, Outcome 3 Repeat surgery needed within 6 mths.
12.4
12.4. Analysis
Comparison 12 PERCUTANEOUS ENDOSCOPIC DISCECTOMY (ANY TYPE) V. MICRODISCECTOMY, Outcome 4 SF‐36 Physical Functioning.
13.1
13.1. Analysis
Comparison 13 PERCUTANEOUS ENDOSCOPIC DISCECTOMY (ANY TYPE) AND SUBSEQUENT MICRODISCECTOMY IF FAILURE V. MICRODISCECTOMY, Outcome 1 No success at 2 yrs ‐ Patient rated.
13.2
13.2. Analysis
Comparison 13 PERCUTANEOUS ENDOSCOPIC DISCECTOMY (ANY TYPE) AND SUBSEQUENT MICRODISCECTOMY IF FAILURE V. MICRODISCECTOMY, Outcome 2 No success at 1yr ‐ Independent observer rated.
14.1
14.1. Analysis
Comparison 14 LASER DISCECTOMY ‐V‐ CHYMOPAPAIN, Outcome 1 Secondary surgery.
14.2
14.2. Analysis
Comparison 14 LASER DISCECTOMY ‐V‐ CHYMOPAPAIN, Outcome 2 Failure at unknown time.
15.1
15.1. Analysis
Comparison 15 GELFOAM V. NO INTERPOSITION MEMBRANE, Outcome 1 Poor result at 1yr ‐ independent observer rated.
15.2
15.2. Analysis
Comparison 15 GELFOAM V. NO INTERPOSITION MEMBRANE, Outcome 2 Moderate scar formation (MRI assessment).
16.1
16.1. Analysis
Comparison 16 FREE FAT GRAFT V. NO INTERPOSITION MEMBRANE, Outcome 1 Poor result at 1yr ‐ observer rated.
16.2
16.2. Analysis
Comparison 16 FREE FAT GRAFT V. NO INTERPOSITION MEMBRANE, Outcome 2 Severe scar formation (MRI/ CT assessment).
16.3
16.3. Analysis
Comparison 16 FREE FAT GRAFT V. NO INTERPOSITION MEMBRANE, Outcome 3 Poor result ‐ patient rated at 1or 2 years.
17.1
17.1. Analysis
Comparison 17 VIDEO‐ASSISTED ARTHROSCOPIC MICRODISCECTOMY V. OPEN DISCECTOMY, Outcome 1 Poor result ‐ Surgeon rated at 2 years.
17.2
17.2. Analysis
Comparison 17 VIDEO‐ASSISTED ARTHROSCOPIC MICRODISCECTOMY V. OPEN DISCECTOMY, Outcome 2 Poor result ‐ patient rated at 2 years.
18.1
18.1. Analysis
Comparison 18 ADCON‐L GEL V. NO INTERPOSITION MEMBRANE, Outcome 1 Roland & Morris Disability Score (US results).
18.2
18.2. Analysis
Comparison 18 ADCON‐L GEL V. NO INTERPOSITION MEMBRANE, Outcome 2 Scarring on MRI (>75% in most involved segment) at 12 months (European results).
18.3
18.3. Analysis
Comparison 18 ADCON‐L GEL V. NO INTERPOSITION MEMBRANE, Outcome 3 Scarring on MRI (>75% in most involved segment) at 6 months.
18.4
18.4. Analysis
Comparison 18 ADCON‐L GEL V. NO INTERPOSITION MEMBRANE, Outcome 4 Poor result ‐ patient rating (US results).
18.5
18.5. Analysis
Comparison 18 ADCON‐L GEL V. NO INTERPOSITION MEMBRANE, Outcome 5 Failure to return to work at 6 months (US results).
18.6
18.6. Analysis
Comparison 18 ADCON‐L GEL V. NO INTERPOSITION MEMBRANE, Outcome 6 Re‐operation at 6 months (US results).
18.7
18.7. Analysis
Comparison 18 ADCON‐L GEL V. NO INTERPOSITION MEMBRANE, Outcome 7 Reoperation at 6 months (European results).
18.8
18.8. Analysis
Comparison 18 ADCON‐L GEL V. NO INTERPOSITION MEMBRANE, Outcome 8 Adverse events at 6 months.
19.1
19.1. Analysis
Comparison 19 POLYLACTIC ACID V. NO INTERPOSITION MEMBRANE, Outcome 1 Surgeon rating at 6 months.
20.1
20.1. Analysis
Comparison 20 DIODE LASER V. Nd‐YAG LASER FOR DISCECTOMY, Outcome 1 Repeat surgery.
21.1
21.1. Analysis
Comparison 21 SEQUESTRECTOMY V. MICRODISCECTOMY, Outcome 1 Operating time.
21.2
21.2. Analysis
Comparison 21 SEQUESTRECTOMY V. MICRODISCECTOMY, Outcome 2 Repeat surgery at 18 months.
21.3
21.3. Analysis
Comparison 21 SEQUESTRECTOMY V. MICRODISCECTOMY, Outcome 3 Not satisfied at 6 months.
21.4
21.4. Analysis
Comparison 21 SEQUESTRECTOMY V. MICRODISCECTOMY, Outcome 4 Poor or Moderate rating at 6 months.
22.1
22.1. Analysis
Comparison 22 MICRODISCECTOMY V. EPIDURAL STEROID, Outcome 1 Failure of Epidural Injection.
23.1
23.1. Analysis
Comparison 23 MICROENDOSCOPIC DISCECTOMY V. OPEN DISCECTOMY, Outcome 1 Unsatisfied ‐ patient rating.

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