Prolapsed lumbar discs ('slipped disc', 'herniated disc') account for less than five percent of all low-back problems, but are the most common cause of nerve root pain ('sciatica'). Ninety percent of acute attacks of sciatica settle with non-surgical management. Surgical options are usually considered for more rapid relief in the minority of patients whose recovery is unacceptably slow.
This updated review considers the relative merits of different forms of surgical treatments by collating the evidence from 40 randomized trials and two quasi-randomized controlled trials (5197 participants) on:
(i) Discectomy - surgical removal of part of the disc
(ii) Microdiscectomy - use of magnification to view the disc and nerves during surgery
(iii) Chemonucleolysis - injection of an enzyme into a bulging spinal disc in an effort to reduce the size of the disc
Despite the critical importance of knowing whether surgery is beneficial, only three trials directly compared discectomy with non-surgical approaches. These provide suggestive rather than conclusive results. Overall, surgical discectomy for carefully selected patients with sciatica due to a prolapsed lumbar disc appears to provide faster relief from the acute attack than non-surgical management. However, any positive or negative effects on the lifetime natural history of the underlying disc disease are unclear. Microdiscectomy gives broadly comparable results to standard discectomy. There is insufficient evidence on other surgical techniques to draw firm conclusions.
Trials showed that discectomy produced better outcomes than chemonucleolysis, which in turn was better than placebo. For various reasons including concerns about safety, chemonucleolysis is not commonly used today to treat prolapsed disc.
Many trials provided limited information on complications, but generally included recurrence of symptoms, need for additional surgery and allergic reactions (chemonucleolysis).
Many of the trials had major design weaknesses that introduced considerable potential for bias. Therefore, the conclusions of this review should be read with caution.
Future trials should be designed to reduce potential bias. Future research should explore the optimal timing of surgery, patient-centred outcomes, costs and cost-effectiveness of treatment options, and longer-term results over a lifetime perspective.
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).
Disc prolapse accounts for five percent of low-back disorders but is one of the most common reasons for surgery.
The objective of this review was to assess the effects of surgical interventions for the treatment of lumbar disc prolapse.
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.
Randomized trials (RCT) and quasi-randomized trials (QRCT) of the surgical management of lumbar disc prolapse.
Two review authors assessed trial quality and extracted data from published papers. Additional information was sought from the authors if necessary.
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.