Surgical interventions for lumbar disc prolapse: updated Cochrane Review.
METHODS
An updated Cochrane Review.


OBJECTIVE
To assess the effects of surgical interventions for the treatment of lumbar disc prolapse.


BACKGROUND
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.


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. The evidence for other minimally invasive techniques remains unclear except for chemonucleolysis using chymopapain, which is no longer widely available.
Gibson
J N Alastair
JN
Spinal Unit, Royal Infirmary of Edinburgh and the University of Edinburgh, Edinburgh, Scotland. j.n.a.gibson@blueyonder.co.uk
Waddell
Gordon
G
D002917:Chymopapain / Q000627:therapeutic use; D002921:Cicatrix / Q000517:prevention & control / Q000628:therapy; D017586:Diskectomy / Q000009:adverse effects / Q000706:statistics & numerical data / Q000639:trends; D004388:Dura Mater / Q000601:surgery; D004724:Endoscopy / Q000706:statistics & numerical data / Q000639:trends; D005782:Gels / Q000627:therapeutic use; D006801:Humans; D007403:Intervertebral Disc / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D007404:Intervertebral Disc Chemolysis / Q000706:statistics & numerical data / Q000639:trends; D007405:Intervertebral Disc Displacement / Q000601:surgery*; D053685:Laser Therapy; D008159:Lumbar Vertebrae / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D019635:Neurosurgical Procedures / Q000379:methods / Q000706:statistics & numerical data* / Q000639:trends; D011183:Postoperative Complications / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control; D016032:Randomized Controlled Trials as Topic / Q000706:statistics & numerical data; D012585:Sciatica / Q000601:surgery; D016896:Treatment Outcome
D005782:Gels; D002917:Chymopapain