title: The timing of surgery in lumbar disc prolapse: A systematic review.
abstract: Herniation of nucleus pulposus leading to leg pain is the commonest indication for lumbar spine surgery. However, there is no consensus when to stop conservative treatment and when to consider for surgery. A systematic review of literature was done to find a consensus on the issue of when should surgery be performed for herniation of nucleus pulposus in lumbar spine was conducted. Electronic database searches of Medline, Embase and Pubmed Central were performed to find articles relating to optimum time to operate in patients with herniation of nucleus pulposus in lumbar spine, published between January 1975 and 10 December 2012. The studies were independently screened by two reviewers. Disagreements between reviewers were settled at a consensus meeting. A scoring system based on research design, number of patients at final followup, percentage of patients at final followup, duration of followup, journal impact factor and annual citation index was devised to give weightage to Categorize (A, B or C) each of the articles. Twenty one studies fulfilled the criteria. Six studies were of retrospective design, 13 studies were of Prospective design and two studies were randomized controlled trials. The studies were categorized as: Two articles in category A (highest level of evidence), 12 articles in category B (moderate level of evidence) while seven articles in Category C (poor level of evidence). Category A studies conclude that duration of sciatica prior to surgery made no difference to the outcome of surgery in patients with herniation of nucleus pulposus in the lumbar spine. Ten out of 12 studies in Category B revealed that longer duration of sciatica before surgery leads to poor results while 2 studies conclude that duration of sciatica makes no difference to outcome. In category C, five studies conclude that longer duration of sciatica before surgery leads to poor outcome while two studies find no difference in outcome with regards to duration of sciatica. A qualitative and quantitative analysis was performed which favoured the consensus that longer duration of sciatica leads to poorer outcome. A systematic and critical review of literature revealed that long duration of preoperative leg pain lead to poor outcome for herniation of nucleus pulposus. Only a broad time frame (2-12 months) could be derived from the review of literature due to lack of high quality studies and variable and contrasting results of the existing studies. While surgery performed within six months was most commonly found to lead to good outcome of surgery, further studies are needed to prove this more conclusively. At this stage it is felt that time alone should not be the basis of recommending surgery and multiple other variables should be considered in a shared decision making process between the surgeon and the patient.
authors.affiliation: Department of Orthopaedic Surgery, Orthopaedic Research Institute, St George Hospital Sydney, University of New South Wales, Kogarah, NSW 2217, Australia.
authors.forename: Ashutosh B
authors.initials: AB
authors.lastname: Sabnis
authors.affiliation: Department of Orthopaedic Surgery, Orthopaedic Research Institute, St George Hospital Sydney, University of New South Wales, Kogarah, NSW 2217, Australia.
authors.forename: Ashish D
authors.initials: AD
authors.lastname: Diwan
keywords: Discectomy; disc prolapse; lumbar; microdiscectomy
references.citation: Br J Gen Pract. 2002 Feb;52(475):119-23
references.pmid: 11887877
references.citation: BMJ. 2008 Jun 14;336(7657):1355-8
references.pmid: 18502911
references.citation: Spine (Phila Pa 1976). 2006 Oct 1;31(21):2409-14
references.pmid: 17023847
references.citation: Surg Neurol. 1998 Mar;49(3):263-7; discussion 267-8
references.pmid: 9508112
references.citation: Eur Spine J. 2010 Sep;19(9):1459-67
references.pmid: 20512513
references.citation: Neuroradiology. 2004 Nov;46(11):916-22
references.pmid: 15609071
references.citation: Spine (Phila Pa 1976). 2005 Apr 15;30(8):927-35
references.pmid: 15834338
references.citation: Funct Neurol. 2004 Jan-Mar;19(1):43-9
references.pmid: 15212116
references.citation: Acta Neurochir (Wien). 1994;128(1-4):53-6
references.pmid: 7847144
references.citation: J Neurosurg. 2004 Apr;100(4 Suppl Spine):317-24
references.pmid: 15070138
references.citation: Spine (Phila Pa 1976). 1999 Apr 15;24(8):742-6
references.pmid: 10222523
references.citation: Acta Orthop Scand Suppl. 1993;251:69-70
references.pmid: 8451992
references.citation: J Neurosurg. 1991 Mar;74(3):415-21
references.pmid: 1993906
references.citation: J Bone Joint Surg Br. 2004 May;86(4):546-9
references.pmid: 15174551
references.citation: Neurosurg Rev. 2002 Jun;25(3):162-5
references.pmid: 12135229
references.citation: Neurosci Lett. 1991 Oct 14;131(2):249-52
references.pmid: 1722299
references.citation: Acta Orthop Scand. 1977;48(6):630-4
references.pmid: 607751
references.citation: Br J Anaesth. 2007 Oct;99(4):461-73
references.pmid: 17704089
references.citation: Pain. 1993 Mar;52(3):259-285
references.pmid: 7681556
references.citation: Eur Spine J. 2009 Apr;18(4):538-45
references.pmid: 19132412
references.citation: Spine (Phila Pa 1976). 1995 Mar 15;20(6):665-9
references.pmid: 7604342
references.citation: J Neurosurg. 2000 Apr;92(2 Suppl):131-4
references.pmid: 10763681
references.citation: Brain Res. 1989 Sep 4;496(1-2):357-60
references.pmid: 2804648
references.citation: Stereotact Funct Neurosurg. 1989;52(2-4):219-26
references.pmid: 2657945
references.citation: Spine (Phila Pa 1976). 1997 May 15;22(10):1057-64
references.pmid: 9160462
references.citation: Surg Neurol. 2008 Oct;70(4):398-401; discussion 401-2
references.pmid: 18262618
references.citation: Spine (Phila Pa 1976). 2012 Oct 1;37(21):1791-802
references.pmid: 23018805
references.citation: J Physiol. 1992 Mar;448:765-80
references.pmid: 1593489
references.citation: Stereotact Funct Neurosurg. 1989;52(2-4):120-6
references.pmid: 2657934
references.citation: N Engl J Med. 2007 May 31;356(22):2245-56
references.pmid: 17538084
references.citation: Spine (Phila Pa 1976). 1994 Jun 1;19(11):1201-6
references.pmid: 8073310
references.citation: Spine (Phila Pa 1976). 1996 Jan 15;21(2):225-9
references.pmid: 8720408
references.citation: J Orthop Res. 2000 Sep;18(5):815-20
references.pmid: 11117305
references.citation: Pain. 1992 Jul;50(1):89-100
references.pmid: 1325049
references.citation: J Med Assoc Thai. 2012 May;95(5):674-80
references.pmid: 22994027
references.citation: JAMA. 2006 Nov 22;296(20):2441-50
references.pmid: 17119140
references.citation: Pain. 1990 Aug;42(2):205-213
references.pmid: 2247318
references.citation: Spine (Phila Pa 1976). 1993 Sep 1;18(11):1433-8
references.pmid: 8235813
references.citation: N Engl J Med. 1988 Feb 4;318(5):291-300
references.pmid: 2961994
references.citation: J Bone Joint Surg Am. 2011 Oct 19;93(20):1906-14
references.pmid: 22012528
references.citation: Spine (Phila Pa 1976). 1987 Nov;12(9):933-8
references.pmid: 3441840
references.citation: Spine (Phila Pa 1976). 1989 Apr;14(4):431-7
references.pmid: 2718047
references.citation: Instr Course Lect. 1992;41:217-23
references.pmid: 1534104
references.citation: Spine (Phila Pa 1976). 1990 Jul;15(7):674-8
references.pmid: 2218714
references.citation: Spine (Phila Pa 1976). 2002 Feb 15;27(4):380-6
references.pmid: 11840104
references.citation: Exp Brain Res. 2007 May;179(1):111-9
references.pmid: 17103209
references.citation: Prilozi. 2008 Dec;29(2):325-35
references.pmid: 19259056
references.citation: Spine (Phila Pa 1976). 1992 Jun;17(6 Suppl):S129-32
references.pmid: 1631712
references.citation: J Orthop Sci. 2010 May;15(3):294-8
references.pmid: 20559795
references.citation: J Spinal Disord. 1990 Sep;3(3):205-9
references.pmid: 2134430
references.citation: Spine (Phila Pa 1976). 1983 Mar;8(2):131-40
references.pmid: 6857385
references.citation: Spine (Phila Pa 1976). 1988 Dec;13(12):1418-22
references.pmid: 3212575
references.citation: Spine (Phila Pa 1976). 1979 Mar-Apr;4(2):150-5
references.pmid: 162551
references.citation: Spine (Phila Pa 1976). 1995 Feb 15;20(4):460-8
references.pmid: 7747230
references.citation: Spine (Phila Pa 1976). 1996 Jan 15;21(2):218-24
references.pmid: 8720407