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Clinician Article

Surgical versus non-operative treatment for lumbar disc herniation: a systematic review and meta-analysis.



  • Chen BL
  • Guo JB
  • Zhang HW
  • Zhang YJ
  • Zhu Y
  • Zhang J, et al.
Clin Rehabil. 2018 Feb;32(2):146-160. doi: 10.1177/0269215517719952. Epub 2017 Jul 17. (Review)
PMID: 28715939
Read abstract Read evidence summary
Disciplines
  • Family Medicine (FM)/General Practice (GP)
    Relevance - 6/7
    Newsworthiness - 6/7
  • General Internal Medicine-Primary Care(US)
    Relevance - 6/7
    Newsworthiness - 6/7
  • Internal Medicine
    Relevance - 6/7
    Newsworthiness - 5/7
  • Surgery - Orthopaedics
    Relevance - 6/7
    Newsworthiness - 5/7
  • FM/GP/Anesthesia
    Relevance - 5/7
    Newsworthiness - 4/7
  • Neurology
    Relevance - 5/7
    Newsworthiness - 4/7

Abstract

OBJECTIVE: To investigate the effects of surgical versus non-operative treatment on the physical function and safety of patients with lumbar disc herniation.

DATA SOURCES: PubMed, Cochrane Library, Embase, EBSCO, Web of Science, China National Knowledge Infrastructure and Chinese Biomedical Literature Database were searched from initiation to 15 May 2017.

METHODS: Randomized controlled trials that evaluated surgical versus non-operative treatment for patients with lumbar disc herniation were selected. The primary outcomes were pain and side-effects. Secondary outcomes were function and health-related quality of life. A random effects model was used to calculate the pooled mean difference with 95% confidence interval.

RESULTS: A total of 19 articles that involved 2272 participants met the inclusion criteria. Compared with non-operative treatment, surgical treatment was more effective in lowering pain (short term: mean difference = -0.94, 95% confidence interval = -1.87 to -0.00; midterm: mean difference = -1.59, 95% confidence interval = -2.24 to -9.94), improving function (midterm: mean difference = -7.84, 95% confidence interval = -14.00 to -1.68; long term: mean difference = -12.21, 95% confidence interval = -23.90 to -0.52) and quality of life. The 36-item Short-Form Health Survey for physical functions (short term: mean difference = 6.25, 95% confidence interval = 0.43 to 12.08) and bodily pain (short term: mean difference = 5.42, 95% confidence interval = 0.40 to 10.45) was also utilized. No significant difference was observed in adverse events (mean difference = 0.82, 95% confidence interval = 0.28 to 2.38).

CONCLUSION: Low-quality evidence suggested that surgical treatment is more effective than non-operative treatment in improving physical functions; no significant difference was observed in adverse events. No firm recommendation can be made due to instability of the summarized data.


Clinical Comments

General Internal Medicine-Primary Care(US)

Good information but we need better studies.

Neurology

The authors deserve credit for an objective analysis of the literature on the effectiveness of lumbar disk surgery for improvements in function and quality of life. The quality of studies, from an epidemiological viewpoint, is poor with considerable heterogeneity and inconsistent blinding and variable follow-ups. Also, by its very nature, lumbar disk disease can cause highly variable pathology, so lumping cases together is problematic. I am not sure what to conclude except that lumbar disk surgery is a viable option for patients with lumbar disk disease. I think the decision will still need to be made on an individual basis. Perhaps a study looking at severity of neurological deficit might be more definitive, but even then, there is a problem having a control group.

Surgery - Orthopaedics

Though we are probably operating too much, in appropriate patients surgery can be more effective than conservative means in improving physical functions and quality of life.

Surgery - Orthopaedics

This is a fair study that breaks the myth of 90-95% conservative treatment in lumbar disk herniation and brings up the value of surgical treatment. Although bias still exist and no current recommendation can be made, this study is valuable to mobilize pts and MDs to think whether surgery may be more beneficial in a higher % of selected cases.

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