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BMJ Clinical Evidence Jun 2011Herniated lumbar disc is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space. The highest prevalence is among... (Review)
Review
INTRODUCTION
Herniated lumbar disc is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space. The highest prevalence is among people aged 30 to 50 years, with a male to female ratio of 2:1. There is little evidence to suggest that drug treatments are effective in treating herniated disc.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of drug treatments, non-drug treatments, and surgery for herniated lumbar disc? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 37 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: acupuncture, advice to stay active, analgesics, antidepressants, bed rest, corticosteroids (epidural injections), cytokine inhibitors (infliximab), discectomy (automated percutaneous, laser, microdiscectomy, standard), exercise therapy, heat, ice, massage, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), percutaneous disc decompression, spinal manipulation, and traction.
Topics: Adrenal Cortex Hormones; Anti-Inflammatory Agents, Non-Steroidal; Diskectomy; Humans; Injections, Epidural; Intervertebral Disc Displacement; Manipulation, Spinal; Traction
PubMed: 21711958
DOI: No ID Found -
The Spine Journal : Official Journal of... Jan 2014The objective of the North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy... (Review)
Review
BACKGROUND CONTEXT
The objective of the North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy is to provide evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of lumbar disc herniation with radiculopathy. The guideline is intended to reflect contemporary treatment concepts for symptomatic lumbar disc herniation with radiculopathy as reflected in the highest quality clinical literature available on this subject as of July 2011. The goals of the guideline recommendations are to assist in delivering optimum efficacious treatment and functional recovery from this spinal disorder.
PURPOSE
To provide an evidence-based educational tool to assist spine specialists in the diagnosis and treatment of lumbar disc herniation with radiculopathy.
STUDY DESIGN
Systematic review and evidence-based clinical guideline.
METHODS
This guideline is a product of the Lumbar Disc Herniation with Radiculopathy Work Group of NASS' Evidence-Based Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. A literature search addressing each question and using a specific search protocol was performed on English-language references found in Medline, Embase (Drugs and Pharmacology), and four additional evidence-based databases to identify articles. The relevant literature was then independently rated using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were developed via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Level I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.
RESULTS
Twenty-nine clinical questions were formulated and addressed, and the answers are summarized in this article. The respective recommendations were graded by strength of the supporting literature, which was stratified by levels of evidence.
CONCLUSIONS
The clinical guideline has been created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients with symptomatic lumbar disc herniation with radiculopathy. The entire guideline document, including the evidentiary tables, suggestions for future research, and all the references, is available electronically on the NASS Web site at http://www.spine.org/Pages/PracticePolicy/ClinicalCare/ClinicalGuidlines/Default.aspx and will remain updated on a timely schedule.
Topics: Diskectomy; Evidence-Based Medicine; Glucocorticoids; Humans; Injections, Epidural; Intervertebral Disc Displacement; Radiculopathy; Recovery of Function; Treatment Outcome
PubMed: 24239490
DOI: 10.1016/j.spinee.2013.08.003 -
BMJ Clinical Evidence Mar 2009Herniated lumbar disc is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space. The highest prevalence is among... (Review)
Review
INTRODUCTION
Herniated lumbar disc is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space. The highest prevalence is among people aged 30-50 years, with a male to female ratio of 2:1. There is little evidence to suggest that drug treatments are effective in treating herniated disc.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of drug treatments, non-drug treatments, and surgery for herniated lumbar disc? We searched: Medline, Embase, The Cochrane Library, and other important databases up to July 2008 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 49 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: acupuncture, advice to stay active, analgesics, antidepressants, bed rest, corticosteroids (epidural injections), cytokine inhibitors (infliximab), discectomy (automated percutaneous, laser, microdisectomy, standard), exercise therapy, heat, ice, massage, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), percutaneous disc decompression, spinal manipulation, and traction.
Topics: Anti-Inflammatory Agents, Non-Steroidal; Diskectomy; Humans; Intervertebral Disc Displacement; Manipulation, Spinal; Sciatica; Treatment Outcome
PubMed: 19445754
DOI: No ID Found -
Acta Ortopedica Mexicana 2014Various programs and interventions are available for the rehabilitation of patients who have undergone surgery for symptomatic lumbar disc herniation (LDH). Our aim is... (Review)
Review
UNLABELLED
Various programs and interventions are available for the rehabilitation of patients who have undergone surgery for symptomatic lumbar disc herniation (LDH). Our aim is to determine the value of the different rehabilitation interventions included in the postoperative treatment of patients with symptomatic LDH.
MATERIAL AND METHODS
Systematic review. Search in electronic data bases--from January 2000 to October 2012. Two independent reviewers certified in the use of the PEDro (Physiotherapy Evidence Data Base) scale assessed the clinical trials included in the final version; only those with high methodological quality were included. A third reviewer acted as arbitrator in case of discrepancy between reviewers. The reviewers were blinded to the authors, institutions and journals to increase the precision of their ratings and the inter-reviewer validity.
RESULTS
Fifteen clinical trials were reviewed by the reviewers; 8 (53.3%) were considered as having a high methodological quality (average of 7.7/10). Were randomized 1099 participants to different treatment groups. It was not possible to conduct a meta-analysis with the clinical trial data due to the multiple interventions and outcome measures used.
CONCLUSIONS
An immediate rehabilitation program is recommended in patients undergoing microiskectomy for the first time. Cognitive intervention with positive reinforcement together with exercise is an effective treatment. It is even considered as an alternative to vertebral fusion in patients who underwent LDH surgery with symptom recurrence after the first surgery. The results of early postoperative activity are usually excellent and involve no complications. The number and the methodological quality of the clinical trials on this topic need to be increased to justify the usefulness of these interventions in the daily clinical practice.
Topics: Cognitive Behavioral Therapy; Diskectomy; Exercise Therapy; Humans; Intervertebral Disc Displacement; Lumbar Vertebrae; Outcome Assessment, Health Care; Physical Therapy Modalities; Postoperative Period; Time Factors
PubMed: 26040154
DOI: No ID Found -
Spine Apr 2021Systematic review and meta-analysis. (Comparative Study)
Comparative Study Meta-Analysis
STUDY DESIGN
Systematic review and meta-analysis.
OBJECTIVE
To give a systematic overview of effectiveness of percutaneous transforaminal endoscopic discectomy (PTED) compared with open microdiscectomy (OM) in the treatment of lumbar disk herniation (LDH).
SUMMARY OF BACKGROUND DATA
The current standard procedure for the treatment of sciatica caused by LDH, is OM. PTED is an alternative surgical technique which is thought to be less invasive. It is unclear if PTED has comparable outcomes compared with OM.
METHODS
Multiple online databases were systematically searched up to April 2020 for randomized controlled trials and prospective studies comparing PTED with OM for LDH. Primary outcomes were leg pain and functional status. Pooled effect estimates were calculated for the primary outcomes only and presented as standard mean differences (SMD) with their 95% confidence intervals (CI) at short (1-day postoperative), intermediate (3-6 months), and long-term (12 months).
RESULTS
We identified 2276 citations, of which eventually 14 studies were included. There was substantial heterogeneity in effects on leg pain at short term. There is moderate quality evidence suggesting no difference in leg pain at intermediate (SMD 0.05, 95% CI -0.10-0.21) and long-term follow-up (SMD 0.11, 95% CI -0.30-0.53). Only one study measured functional status at short-term and reported no differences. There is moderate quality evidence suggesting no difference in functional status at intermediate (SMD -0.09, 95% CI -0.24-0.07) and long-term (SMD -0.11, 95% CI -0.45-0.24).
CONCLUSION
There is moderate quality evidence suggesting no difference in leg pain or functional status at intermediate and long-term follow-up between PTED and OM in the treatment of LDH. High quality, robust studies reporting on clinical outcomes and cost-effectiveness on the long term are lacking.Level of Evidence: 2.
Topics: Cost-Benefit Analysis; Diskectomy, Percutaneous; Endoscopy; Humans; Intervertebral Disc Degeneration; Intervertebral Disc Displacement; Lumbar Vertebrae; Microsurgery; Pain Measurement; Prospective Studies; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 33290374
DOI: 10.1097/BRS.0000000000003843 -
The Cochrane Database of Systematic... Mar 2014Several rehabilitation programmes are available for individuals after lumbar disc surgery. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Several rehabilitation programmes are available for individuals after lumbar disc surgery.
OBJECTIVES
To determine whether active rehabilitation after lumbar disc surgery is more effective than no treatment, and to describe which type of active rehabilitation is most effective. This is the second update of a Cochrane Review first published in 2002.First, we clustered treatments according to the start of treatment.1. Active rehabilitation that starts immediately postsurgery.2. Active rehabilitation that starts four to six weeks postsurgery.3. Active rehabilitation that starts longer than 12 months postsurgery.For every cluster, the following comparisons were investigated.A. Active rehabilitation versus no treatment, placebo or waiting list control.B. Active rehabilitation versus other kinds of active rehabilitation.C. Specific intervention in addition to active rehabilitation versus active rehabilitation alone.
SEARCH METHODS
We searched CENTRAL (2013, Issue 4) and MEDLINE, EMBASE, CINAHL, PEDro and PsycINFO to May 2013.
SELECTION CRITERIA
We included only randomised controlled trials (RCTs).
DATA COLLECTION AND ANALYSIS
Pairs of review authors independently assessed studies for eligibility and risk of bias. Meta-analyses were performed if studies were clinically homogeneous. The GRADE approach was used to determine the overall quality of evidence.
MAIN RESULTS
In this update, we identified eight new studies, thereby including a total of 22 trials (2503 participants), 10 of which had a low risk of bias. Most rehabilitation programmes were assessed in only one study. Both men and women were included, and overall mean age was 41.4 years. All participants had received standard discectomy, microdiscectomy and in one study standard laminectomy and (micro)discectomy. Mean duration of the rehabilitation intervention was 12 weeks; eight studies assessed six to eight-week exercise programmes, and eight studies assessed 12 to 13-week exercise programmes. Programmes were provided in primary and secondary care facilities and were started immediately after surgery (n = 4) or four to six weeks (n = 16) or one year after surgery (n = 2). In general, the overall quality of the evidence is low to very low. Rehabilitation programmes that started immediately after surgery were not more effective than their control interventions, which included exercise. Low- to very low-quality evidence suggests that there were no differences between specific rehabilitation programmes (multidisciplinary care, behavioural graded activity, strength and stretching) that started four to six weeks postsurgery and their comparators, which included some form of exercise. Low-quality evidence shows that physiotherapy from four to six weeks postsurgery onward led to better function than no treatment or education only, and that multidisciplinary rehabilitation co-ordinated by medical advisors led to faster return to work than usual care. Statistical pooling was performed only for three comparisons in which the rehabilitation programmes started four to six weeks postsurgery: exercise programmes versus no treatment, high- versus low-intensity exercise programmes and supervised versus home exercise programmes. Very low-quality evidence (five RCTs, N = 272) shows that exercises are more effective than no treatment for pain at short-term follow-up (standard mean difference (SMD) -0.90; 95% confidence interval (CI) -1.55 to -0.24), and low-quality evidence (four RCTs, N = 252) suggests that exercises are more effective for functional status on short-term follow-up (SMD -0.67; 95% CI -1.22 to -0.12) and that no difference in functional status was noted on long-term follow-up (three RCTs, N = 226; SMD -0.22; 95% CI -0.49 to 0.04). None of these studies reported that exercise increased the reoperation rate. Very low-quality evidence (two RCTs, N = 103) shows that high-intensity exercise programmes are more effective than low-intensity exercise programmes for pain in the short term (weighted mean difference (WMD) -10.67; 95% CI -17.04 to -4.30), and low-quality evidence (two RCTs, N = 103) shows that they are more effective for functional status in the short term (SMD -0.77; 95% CI -1.17 to -0.36). Very low-quality evidence (four RCTs, N = 154) suggests no significant differences between supervised and home exercise programmes for short-term pain relief (SMD -0.76; 95% CI -2.04 to 0.53) or functional status (four RCTs, N = 154; SMD -0.36; 95% CI -0.88 to 0.15).
AUTHORS' CONCLUSIONS
Considerable variation was noted in the content, duration and intensity of the rehabilitation programmes included in this review, and for none of them was high- or moderate-quality evidence identified. Exercise programmes starting four to six weeks postsurgery seem to lead to a faster decrease in pain and disability than no treatment, with small to medium effect sizes, and high-intensity exercise programmes seem to lead to a slightly faster decrease in pain and disability than is seen with low-intensity programmes, but the overall quality of the evidence is only low to very low. No significant differences were noted between supervised and home exercise programmes for pain relief, disability or global perceived effect. None of the trials reported an increase in reoperation rate after first-time lumbar surgery. High-quality randomised controlled trials are strongly needed.
Topics: Diskectomy; Exercise Therapy; Female; Humans; Intervertebral Disc; Laminectomy; Lumbar Vertebrae; Male; Postoperative Period; Randomized Controlled Trials as Topic; Recovery of Function
PubMed: 24627325
DOI: 10.1002/14651858.CD003007.pub3 -
Global Spine Journal Feb 2017Systematic review and meta-analysis. (Review)
Review
STUDY DESIGN
Systematic review and meta-analysis.
OBJECTIVE
Anterior cervical diskectomy and fusion (ACDF) is an effective surgical option for patients with cervical radiculopathy, myelopathy, or deformity. Although ACDF is generally safe, dysphagia is a common complication. Despite its high incidence, prolonged postoperative dysphagia is poorly understood; its etiology remains relatively unknown, and its risk factors are widely debated.
METHODS
We searched MEDLINE, Scopus, Web of Science, and Embase for studies reporting complications for cervical diskectomy with plating. We recorded dysphagia events from all included studies and calculated effect summary values, 95% confidence intervals (CIs), Q values, and values.
RESULTS
Of the 7,780 retrieved articles, 14 met inclusion criteria. The overall dysphagia rate was 8.5% (95% CI 5.7 to 11.3%). The rate of moderate or severe dysphagia was 4.4% (0.4 to 8.4%). Follow-up times of <12, 12 to 24, and >24 months reported rates of 19.9% (6.0 to 33.7%), 7.0% (5.2 to 8.7%), and 7.6% (1.4 to 13.8%), respectively. Studies utilizing the Bazaz Dysphagia Score resulted in an increase in dysphagia diagnosis relative to studies with no outlined criteria (19.8%, 5.9 to 33.7% and 6.9%, 3.7 to 10.0%, respectively), indicating that the criteria used for dysphagia identification are critical. There was no difference in dysphagia rate with the use of autograft versus allograft.
CONCLUSIONS
This review represents a comprehensive estimation of the actual incidence of dysphagia across a heterogeneous group of surgeons, patients, and criteria. The classification scheme for dysphagia varied significantly within the literature. To ensure its diagnosis and identification, we recommend the use of a standardized, well-outlined method for dysphagia diagnosis.
PubMed: 28451514
DOI: 10.1055/s-0036-1583944 -
Spine Apr 2023A systematic review of the literature to develop an algorithm formulated by key opinion leaders.
STUDY DESIGN
A systematic review of the literature to develop an algorithm formulated by key opinion leaders.
OBJECTIVE
This study aimed to analyze currently available data and propose a decision-making algorithm for full-endoscopic lumbar discectomy for treating lumbar disc herniation (LDH) to help surgeons choose the most appropriate approach [transforaminal endoscopic lumbar discectomy (TELD) or interlaminar endoscopic lumbar discectomy (IELD)] for patients.
SUMMARY OF BACKGROUND DATA
Full-endoscopic discectomy has gained popularity in recent decades. To our knowledge, an algorithm for choosing the proper surgical approach has never been proposed.
MATERIALS AND METHODS
A systematic review of the literature using PubMed and MeSH terms was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Patient samples included patients with LDH treated with full-endoscopic discectomy. The inclusion criteria were interventional research (randomized and nonrandomized trials) and observation research (cohort, case-control, case series). Exclusion criteria were case series and technical reports. The criteria used for selecting patients were grouped and analyzed. Then, an algorithm was generated based on these findings with support and reconfirmation from key expert opinions. Data on overall complications were collected. Outcome measures included zone of herniation, level of herniation, and approach (TELD or IELD).
RESULTS
In total, 474 articles met the initial screening criteria. The detailed analysis identified the 80 best-matching articles; after applying the inclusion and exclusion criteria, 53 articles remained for this review.
CONCLUSIONS
The proposed algorithm suggests a TELD for LDH located in the foraminal or extraforaminal zones at upper and lower levels and for central and subarticular discs at the upper levels considering the anatomic foraminal features and the craniocaudal pathology location. An IELD is preferred for LDH in the central or subarticular zones at L4/L5 and L5/S1, especially if a high iliac crest or high-grade migration is found.
Topics: Humans; Diskectomy, Percutaneous; Lumbar Vertebrae; Diskectomy; Intervertebral Disc Displacement; Endoscopy; Treatment Outcome; Retrospective Studies
PubMed: 36745468
DOI: 10.1097/BRS.0000000000004589 -
World Neurosurgery Oct 2023There are no systematic evidence-based medical data on the complications of endoscopic cervical spinal surgery. This narrative analysis compiled data from various... (Review)
Review
BACKGROUND
There are no systematic evidence-based medical data on the complications of endoscopic cervical spinal surgery. This narrative analysis compiled data from various studies that examined endoscopic complications, such as cervical disc herniation and foraminal stenosis. This study aimed to investigate the efficacy and safety of endoscopic surgery in cervical radiculopathy.
METHODS
We searched the PubMed/MEDLINE databases to identify articles on endoscopic spinal surgery, and keywords were set as "endoscopic cervical spinal surgery", "endoscopic cervical discectomy", "endoscopic cervical foraminotomy", and "percutaneous endoscopic cervical discectomy". We analyzed the evidence level and classified the prescribed complications according to the literature. Endoscopic cervical surgery was divided into three categories: full endoscopic anterior, endoscopic posterior, and unilateral biportal approaches. We excluded duplicate publications, studies without full text, studies without complications or incomplete information, and studies that did not provide the necessary data for extraction, animal experiments, or reviews.
RESULTS
Difficulties in swallowing, hematoma, and hoarseness are common complications associated with the anterior cervical approach. In contrast, complications of the posterior approach include nerve root injury, hematoma, and dysesthesia. However, endoscopic cervical spinal surgery, including the full endoscopic anterior, posterior, and unilateral biportal approaches, is a safe and effective treatment for cervical radiculopathy.
CONCLUSIONS
Complications of full endoscopic cervical spinal surgery differ significantly depending on the anterior and posterior approaches. In the anterior approach, swallowing difficulty, recurrent disc, hematoma, and dysphonia are the common complications. In contrast, transient dysesthesia, dural tears, upper limb motor deficits, and persistent arm pain are commonly reported with the posterior approach.
Topics: Humans; Radiculopathy; Paresthesia; Cervical Vertebrae; Endoscopy; Intervertebral Disc Displacement; Diskectomy; Hematoma; Treatment Outcome; Retrospective Studies
PubMed: 37479028
DOI: 10.1016/j.wneu.2023.07.058 -
Medicine Feb 2019Systematic review with network meta-analysis.
STUDY DESIGN
Systematic review with network meta-analysis.
OBJECTIVE
To compare patient outcomes of lumbar discectomy with bone-anchored annular closure (LD + AC), lumbar discectomy (LD), and continuing conservative care (CC) for treatment of lumbar disc herniation refractory to initial conservative management.
SUMMARY OF BACKGROUND DATA
Several treatment options are available to patients with refractory symptoms of lumbar disc herniation, but their comparative efficacy is unclear.
METHODS
A systematic review was performed to compare efficacy of LD + AC, LD, and CC for treatment of lumbar disc herniation. Outcomes included leg pain, back pain, disability (each reported on a 0-100 scale), reherniation, and reoperation. Data were analyzed using random effects network meta-analysis.
RESULTS
This review included 14 comparative studies (8 randomized) involving 3947 patients-11 studies of LD versus CC (3232 patients), 3 studies of LD + AC versus LD (715 patients), and no studies of LD + AC versus CC. LD was more effective than CC in reducing leg pain (mean difference [MD] -10, P < .001) and back pain (MD -7, P < .001). LD + AC was more effective than LD in reducing risk of reherniation (odds ratio 0.38, P < .001) and reoperation (odds ratio 0.33, P < .001). There was indirect evidence that LD + AC was more effective than CC in reducing leg pain (MD -25, P = .003), back pain (MD -20, P = .02), and disability (MD -13, P = .02) although the treatment effect was smaller in randomized trials.
CONCLUSIONS
Results of a network meta-analysis show LD is more effective than CC in alleviating symptoms of lumbar disc herniation refractory to initial conservative management. Further, LD + AC lowers risk of reherniation and reoperation versus LD and may improve patient symptoms more than CC.
Topics: Age Factors; Bone-Anchored Prosthesis; Conservative Treatment; Disability Evaluation; Diskectomy; Humans; Intervertebral Disc Displacement; Lumbar Vertebrae; Network Meta-Analysis; Pain; Reoperation; Sex Factors
PubMed: 30762743
DOI: 10.1097/MD.0000000000014410