Abstract
Background
Lumbar disc herniation (LDH) is a prevalent spinal disorder that imposes substantial health burdens in the form of chronic pain and mobility limitations, particularly in working-age populations. Due to advancements in technology and materials, the treatments for LDH are constantly being updated.
Purpose
The purpose of this systematic review and network meta-analysis (NMA) was to compare the outcomes of different LDH treatments.
Study design
A NMA of randomized controlled trials (RCTs) comparing various treatments for LDH.
Methods
This review was conducted in accordance with to the PRISMA-P guidelines. The PubMed, Embase, Medline, and Cochrane Library electronic databases were systematically searched from 2007 to March 2024 to identify RCTs comparing various treatments for LDH. The outcomes of interest included changes in the pain score, disability score and recurrence rate at the one-year follow-up. The risk of bias among the included studies was assessed using the Cochrane method. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was tailored for network meta-analysis and used to evaluate the overall certainty of the evidence regarding each outcome. This study employed a frequentist approach to conduct the NMA, and all procedures were carried out using the network package in Stata 14.2. The PROSPERO number was CRD42024578677.
Results
Twenty-seven RCTs involving 4633 participants and seven treatment strategies were included. Compared with conservative treatments, all surgical interventions demonstrated better efficacy in pain relief and disability recovery. Among the surgical options, endoscopic discectomy with internal fixation (EDF), percutaneous endoscopic discectomy (PED), microdiscectomy (MD) and open discectomy (OD) were found to be significantly superior to conservative treatments, with EDF showing the best performance. Surface under the cumulative ranking curve (SUCRA) plots displayed the same trend as the NMA results. No significant differences were observed in terms of recurrence rates. However, the SUCRA plots indicated that EDF ranked best in terms of recurrence rates. The GRADE assessment revealed that the quality of most of the evidence was low or very low.
Conclusion
The implantation of internal fixation devices was shown to have no impact on quality of life. EDF appears highly effective, especially for pain relief, but other less invasive options, such as PED, have similarly good outcomes in many respects.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12893-025-02992-9.
Keywords: Lumbar disc herniation, Different treatments, A network meta-analysis
Introduction
Lumbar disc herniation (LDH) refers to the displacement of disc material beyond the intervertebral space, which may compress nearby structures such as nerve roots and the spinal canal and can cause some symptoms. LDH is a common cause of lower back and leg pain and can even lead to lower limb numbness, muscle weakness and incontinence in severe cases [1]. Approximately 5 to 20 cases of LDH occur per 1,000 adults annually [2], with the incidence significantly increasing among individuals in their 20s, 30s, 50s, and 70s [3]. Although the prevalence of LDH varies across different countries and regions, it remains a global health challenge that poses a burden to health care systems and economies worldwide. Therefore, it is essential to understand and manage LDH effectively to alleviate patient suffering and mitigate the societal burden.
Conservative treatments are often the preferred and well-accepted approach among LDH patients because of their noninvasive nature. Additionally, 13–96% of LDH patients experience spontaneous resolution of their symptoms [4]. The conservative treatments include nonsteroidal anti-inflammatory drugs; physical therapies such as traction, massage and electrical stimulation; strengthening core muscles to support the spine; lifestyle modifications such as improved posture and weight management; and corticosteroid injections for serious cases and other medications [5]. Moreover, surgical treatment has evolved significantly over time. In 1940, laminectomy became the standard open discectomy (OD) procedure. In the 1980s, open decompression and internal fixation (ODF) were successfully performed using pedicle screws, restoring lumbar spine stability [6]. In the 1970s, microdiscectomy (MD) emerged as a technique for removing herniated discs through a small incision and microscope [7]; this technique was followed by percutaneous endoscopic discectomy (PED) [8], which has since been refined and popular with advancements in endoscopic imaging technology. In 2013, unilateral biportal endoscopy (UBE) was first applied clinically in South Korea and was gradually introduced in other countries [9]. UBE overcomes the limitations of traditional single-channel endoscopy by enabling simultaneous endoscopic observation and surgical operation through dual approaches. In the mid-2000s, endoscopic discectomy and fixation (EDF) emerged [10], combining the benefits of minimal invasion and traditional spinal fusion.
Treatment methods for LDH are continually evolving, and many recent articles have compared the disparities among different treatment options. For example, Liu et al. [11] reported very low- to low-certainty evidence suggesting that discectomy is superior to nonsurgical treatment. Costa et al. [12] reported that minimally invasive surgery was more effective; however, they did not recommend specific surgical methods. These findings indicate that the effect of surgical intervention remains unclear. Moreover, discectomy or minimally invasive surgery constitute a large category, and examining different surgical procedures separately may lead to more satisfying results. Rickers et al. [13] compared the efficacy of 8 treatment strategies via network meta-analysis (NMA) but did not include two emerging surgical methods, namely, UBE and EDF. Compared with PED, UBE provides a better surgical field of view and a more convenient operating space, facilitating thorough removal of herniated discs. Additionally, EDF not only removes the herniated disc under minimally invasive conditions but also reestablishes spine stability. Although they are new technologies, patients have high acceptance and recognition of them in clinical practice. Therefore, this NMA was conducted to compare the efficacy of the latest LDH treatments. These findings can aid in choosing the optimal treatment strategy for LDH patients.
Materials and methods
Literature search
The PubMed, Embase, Medline, and Cochrane Library electronic database were searched from 2007 to March 2024. The search strategy (Supplementary Table 1) utilized key terms such as lumbar disc herniation, intervertebral disc, discectomy, and randomized controlled trial (RCT), along with suitable operators. No language restrictions were applied. Furthermore, a manual search of the pertinent literature was conducted to identify eligible studies for inclusion. The PROSPERO number was CRD42024578677.
Inclusion and exclusion criteria
Only RCTs treating primary LDH were included. The present study evaluated seven groups of contemporary treatment strategies (Table 1): conservative treatment, open discectomy (OD), microdiscectomy (MD), percutaneous endoscopic discectomy (PED), unilateral biportal endoscopic discectomy (UBE), endoscopic discectomy with internal fixation (EDF), and open discectomy with internal fixation (ODF). The inclusion criterion was the analysis of one of the following outcomes: pain measured by the visual analogue scale (VAS) or numeric rating scale (NRS), disability assessed by the Oswestry Disability Index (ODI) or the Roland–Morris Index (RMI), or the recurrence rate. The exclusion criteria were as follows: (1) letters, case series, reviews, retrospective studies, and single-arm prospective cohorts; (2) patients with unexplained lower back pain; or (3) specific herniation subtypes, such as sequestered or axillary herniations, or studies focused solely on disc herniation at a particular level.
Table 1.
Overview of treatment groups
| Treatments | |
|---|---|
| Cons | Conservative treatment |
| OD | Open discectomy, performed under direct visual inspection |
| MD |
Microdiscectomy, with assistance from a loupe or operation microscope sssmicro |
| PED | Percutaneous endoscopic discectomy, unilateral single-channel |
| UBE | Unilateral biportal endoscopic discectomy, unilateral double-channel |
| EDF | Endoscopic discectomy with internal fixation, for example, using annular |
| closure device to repair annulus fibrous defect or implant pedicle screw | |
| for intervertebral fusion | |
| ODF | Open discectomy with internal fixation |
Data extraction and assessment of study quality
Duplicate studies were removed by importing the search results from the electronic databases into Endnote X9. Both authors independently assessed all titles and abstracts during the initial review, excluding unrelated articles. The final articles were chosen on the basis of the inclusion and exclusion criteria after a full-text review. Differences between the reviewers were resolved by consensus or by consulting a third reviewer. Data extracted from the included studies were incorporated into a customized Excel table. The extracted items included the first author, publication year, country, treatment and comparator, sample size, sex ratio, mean age, follow-up period and symptom duration. The outcomes considered for NMA were pain scores (prioritizing leg pain if specified by location), disability scores and recurrence rates. Conservative treatment cohort: Recurrence was defined as (1) reappearance of clinically significant low back pain with radicular symptoms, (2) confirmed by MRI evidence of reherniation at the index level, regardless of subsequent treatment decisions. Surgical treatment cohort: Recurrence was strictly defined as reoperation at the same spinal level. This NMA included one-year follow-up data (for studies with less than one year of follow-up, the final follow-up data were selected). Another reviewer evaluated the risk of bias (ROB) in individual studies using the Cochrane method [14]. Additionally, the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) [15] approach was tailored for network meta-analysis and used to appraise the overall certainty of the evidence regarding each outcome (Supplementary Table 2).
Data syntheses and statistical analysis
Dichotomous outcomes were assessed using relative risk (RR), and continuous outcomes were evaluated using standardized mean differences (SMDs). This study employed a frequentist approach to conduct the NMA, and all procedures were carried out using the network package [16] in Stata 14.2 (Corp LLC, College Station, TX). A network plot was created for each outcome to identify potential comparisons. First, an inconsistency model was employed to assess global inconsistency. If p > 0.05, the inconsistency was not significant, and a consistency model was then applied for analysis. Second, the node-splitting method was employed for the local inconsistency test. If all P values are > 0.05, there is no local inconsistency; otherwise, there is a local inconsistency. The estimated outcome for each relative treatment was derived from both direct evidence between the two treatments and indirect evidence from the NMA. When no direct comparison existed, the estimated outcome relied solely on indirect evidence. Additionally, pairwise meta-analysis was conducted using Review Manager 5.4 to provide direct estimates (RR, SMD, and 95% confidence intervals). A random effects model was applied in the presence of significant heterogeneity; otherwise, a fixed effects model was utilized. We examined the NMA outcomes (indirect results) alongside pairwise meta-analysis outcomes (direct results) to investigate the reasons for discrepancies. The NMA results of different surgical interventions versus conservative treatments were presented in a forest plot. A surface under the cumulative ranking curve (SUCRA) plot was constructed to display the treatment rankings. The combined results of all the comparisons are shown in a league chart.
Results
Systematic review and qualitative assessment
A total of 27 trials [17–43] (n = 4633) and seven approaches (conservative treatment, OD, MD, PED, UBE, EDF and ODF) were included (Fig. 1). Table 2 displays the basic demographic data and treatment of the included studies. Among the 27 trials, two (7.3%) were conducted in the Americas, 14 (51.9%) in Asia, 10 (37.0%) in Europe, and two (7.3%) in Africa.
Fig. 1.
Flowchart for searching and selecting eligible studies. The study screening process and primary elimination reasons: 38 duplicate studies were excluded, 141 studies were excluded after screening the title and abstract, and 65 studies failed to meet the inclusion criteria
Table 2.
Basic demographic data and treatment of studies included
| ID | Study | Country | Treatment (IG/CG) |
Sample size |
Gender (f/m, IG) |
Gender (f/m, CG) |
Mean age |
Follow-up (m) |
Duration of Symptoms(w) |
|---|---|---|---|---|---|---|---|---|---|
| 1 | Abrishamkar 2015 | Iran | MD/OD | 200 | 82/100 | 72/22 | 39.95 | 12 | / |
| 2 | Arts 2009 | Netherland | PED/MD | 325 | 82/84 | 71/88 | 41.45 | 12 | > 6–8 |
| 3 | Kelekis 2022 | Switzerland | Cons/MD | 47 | 7/17 | 9/14 | 40.28 | 6 | > 6 |
| 4 | Chen 2018 | China | PED/MD | 153 | 28/52 | 36/37 | 40.44 | 12 | > 6 |
| 5 | Chen 2020 | China | PED/MD | 241 | 73/46 | 70/52 | 40.95 | 12 | / |
| 6 | Franke 2009 | Germany | PED/MD | 100 | 19/29 | 20/32 | 44 | 12 | / |
| 7 | Gao 2020 | China | EDF/PED | 243 | 61/59 | 63/60 | 45.2 | 12 | > 24 |
| 8 | Gibson 2017 | Britain | PED/MD | 140 | 30/40 | 40/30 | 40.5 | 12 | > 24 |
| 9 | Hamawandi 2020 | Iraq | OD/MD | 60 | 11/19 | 11/19 | 41.35 | 12 | > 6 |
| 10 | Pan 2016 | China | PED/OD | 106 | 22/26 | 27/31 | 41.2 | 12 | / |
| 11 | Kienzler 2019 | Switzerland | EDF/MD | 551 | 116/156 | 108/171 | 40.5 | 12 | > 6 |
| 12 | Wang 2019 | China | PED/MD | 90 | 18/27 | 19/26 | 48.03 | 6 | > 4 |
| 13 | Yadav 2019 | China | PED/ODF | 60 | 15/15 | 16/14 | 57.58 | 6 | > 4 |
| 14 | Lurie 2014 | Lebanon | OD/Cons | 265 | 63/83 | 49/70 | 41.19 | 12 | / |
| 15 | Overdevest 2017 | Netherlands | PED/MD | 325 | 82/84 | 71/88 | 41.45 | 12 | > 8 |
| 16 | Chang 2018 | China | PED/OD | 110 | 20/40 | 20/30 | 52.45 | 3 | > 12 |
| 17 | Park 2023 | South Korea | UBE/MD | 64 | 18/14 | 14/18 | 48 | 12 | > 6 |
| 18 | Peul 2007 | Netherland | OD/Cons | 283 | 52/89 | 45/97 | 42.13 | 6 | / |
| 19 | Thome 2018 | Germany | EDF/OD | 550 | 116/156 | 107/171 | 43.5 | 6 | / |
| 20 | Hussein 2016 | Egypt | MD/OD | 73 | 20/17 | 21/15 | 31.2 | 12 | / |
| 21 | Ran 2021 | China | PED/OD | 68 | 11/24 | 15/18 | 47.68 | 12 | > 12 |
| 22 | Righesso 2007 | Brazil | PED/OD | 40 | 6/13 | 11/10 | 43.9 | 12 | > 6 |
| 23 | Ryang 2008 | German | PED/MD | 68 | 11/24 | 15/18 | 38.65 | 12 | > 6 |
| 24 | Hussein 2014 | Egpyt | MD/OD | 200 | 58/42 | 54/46 | 30.85 | 12 | / |
| 25 | Meyer 2014 | Brazil | PED/MD | 47 | 9/14 | 8/16 | 46.18 | 12 | > 6 |
| 26 | Li 2020 | China | PED/ODF | 42 | 8/13 | 6/15 | 49.65 | 12 | > 12 |
| 27 | He 2022 | China | PED/OD | 94 | 19/28 | 17/30 | 50.15 | 6 | > 12 |
Cons = Conservative treatment; OD = Open discectomy; MD = Microdiscectomy; PED = Percutaneous endoscopic discectomy, unilateral single-channel; UBE = Unilateral biportal endoscopic discectomy, unilateral double-channel; EDF = Endoscopic discectomy with internal fixation; ODF = Open discectomy with internal fixation; IG = Intervention group; CG = Control group
The ROB for each study was assessed using the Cochrane tool [14]. The results of the ROB assessment are shown in Fig. 2; most studies were assessed as having a low or unclear risk of bias. Acknowledging the impossibility of blinding the surgeon and the ethical challenges associated with blinding participants, a high risk of participant and personnel bias was considered acceptable. Regarding detection bias, two studies were considered to have a high risk of bias [17, 19]. Three studies were evaluated as having a high risk of selection bias [22, 25, 31]. Additionally, one study [18] was assessed as having a high risk of bias with respect to incomplete outcome data. The other studies were all assessed as having a low or unclear risk of bias.
Fig. 2.
The results of the ROB assessment, risk of bias summary (A) and graph (B)
Pairwise meta-analysis
Supplementary Table 3 presents direct evidence from the pairwise meta-analysis. The change in pain score was significantly superior in the OD group compared with conservative treatment (SMD 0.97; 95% CI 0.26, 1.68). The disability score was significantly different between the OD group and the conservative treatment group (SMD 0.21; 95% CI 0.06, 0.36), suggesting that EDF was superior. The recurrence rates were not significantly different. The corresponding NMA results were consistent with these two paired meta-analysis results in terms of significance and trend.
NMA results, global consistency and node splitting
Figures 3A and 4A, and 5A illustrate that some treatments lack a closed loop connection to the network. Specifically, the treatments were UBE and ODF for pain scores and disability scores and UBE, OD, ODF and conservative treatment for the recurrence rate. Although node-splitting analysis could not be conducted for these cases, they remain part of the final effect estimation. The NMA included all seven treatments and conducted 11 direct comparisons for the pain score and disability score and 7 direct comparisons for the reoperation rate. The global inconsistency test indicated P values exceeding 0.05 for the pain score, disability score, and recurrence rate. The node-splitting results demonstrated overall consistency, with all comparisons yielding P values greater than 0.05. The following results were analysed using the consistency model.
Fig. 3.
NMA results of pain score. In geometry plot of the network (A), each dot represents a treatment modality, number represents the number of participants and the line between dots shows a direct comparison. Thicker lines indicate more studies. Forest plot (B) displays the NMA results of different surgical interventions versus conservative treatments, in which SMD less than 0 indicates support for surgical interventions. Cons = Conservative treatment; OD = Open discectomy; MD = Microdiscectomy; PED = Percutaneous endoscopic discectomy, unilateral single-channel; UBE = Unilateral biportal endoscopic discectomy, unilateral double-channel; EDF = Endoscopic discectomy with internal fixation; ODF = Open discectomy with internal fixation
Fig. 4.
NMA results of disability score. In geometry plot of the network (A), each dot represents a treatment modality, number represents the number of participants and the line between dots shows a direct comparison. Thicker lines indicate more studies. Forest plot (B) displays the NMA results of different surgical interventions versus conservative treatments, in which SMD less than 0 indicates support for surgical interventions. Cons = Conservative treatment; OD = Open discectomy; MD = Microdiscectomy; PED = Percutaneous endoscopic discectomy, unilateral single-channel; UBE = Unilateral biportal endoscopic discectomy, unilateral double-channel; EDF = Endoscopic discectomy with internal fixation; ODF = Open discectomy with internal fixation
Fig. 5.
NMA results of recurrence rates. In geometry plot of the network (A), each dot represents a treatment modality, number represents the number of participants and the line between dots shows a direct comparison. Thicker lines indicate more studies. Forest plot (B) displays the NMA results of different surgical interventions versus conservative treatments, in which RR value less than 1 indicates support for surgical interventions. Cons = Conservative treatment; OD = Open discectomy; MD = Microdiscectomy; PED = Percutaneous endoscopic discectomy, unilateral single-channel; UBE = Unilateral biportal endoscopic discectomy, unilateral double-channel; EDF = Endoscopic discectomy with internal fixation; ODF = Open discectomy with internal fixation
Pain score
Twenty-six studies with 4487 patients provided usable results for the VAS. EDF (SMD − 0.98; 95% CI -1.82, -0.14), PED (SMD − 0.93; 95% CI -1.61, -0.26), MD (SMD − 0.80; 95% CI -1.47, -0.14) and OD (SMD − 0.78; 95% CI -1.39, -0.17) were significantly different from conservative treatment (Fig. 3B) and were beneficial for pain relief. UBE and ODF outperformed conservative treatment, although the difference was not statistically significant. The pairwise comparisons of the other interventions revealed no statistically significant differences. The SUCRA plot (Supplementary Fig. 1A) provided support for these findings and showed the same trend as the league chart (Supplementary Fig. 1B), in which the pain relief ranking from high to low was as follows: EDF (SUCRA value = 71.1), PED (70.6), UBE (59.8), MD (50.8), OD (47.9), ODF (46.9) and conservative treatment (3.1). The results of the GRADE evaluation (Table 3A), which is based on the conservative principle, indicated low or very low certainty of evidence.
Table 3A.
Effect estimates and grading of recommendations, assessment, development, and evaluations quality ratings for comparison of different interventions for pain score
| Comparison | Direct evidence | Indirect evidence | Network meta-analysis | |||
|---|---|---|---|---|---|---|
| SMD(95% CI)a | Certainty | SMD(95% CI) a | Certainty | SMD(95% CI) a | Certainty | |
| Cons vs. OD | *0.97(0.26,1.68) | Moderateb | 0.23(-0.96,1.42) | Very lowb, c,d | *0.78(0.17,1.39) | Very lowb, c,d |
| Cons vs. MD | 0.32(-0.81,1.45) | Lowb, c | *1.06(0.24,1.87) | Very lowb, c,d | *0.80(0.14,1.47) | Very lowb, c,d |
| Cons vs. PED | NA | *0.93(0.26,1.61) | Very lowb, c,d | *0.93(0.26,1.61) | Very lowb, c,d | |
| Cons vs. UBE | NA | 0.89(-0.39,2.16) | Very lowb, c,d | 0.89(-0.39,2.16) | Very lowb, c,d | |
| Cons vs. EDF | NA | *0.98(0.14,1.82) | Very lowb, c,d | *0.98(0.14,1.82) | Very lowb, c,d | |
| Cons vs. ODF | NA | 0.73(-0.29,1.75) | Very lowb, c,d | 0.73(-0.29,1.75) | Very lowb, c,d | |
| OD vs. MD | -0.07(-0.68,0.54) | Very lowb, c,d | 0.09(-0.42,0.60) | Very lowb, c,d | 0.03(-0.36,0.41) | Very lowb, c,d |
| OD vs. PED | 0.33(-0.14,0.80) | Lowb, c | -0.1(-0.68,0.48) | Very lowb, c,d | 0.15(-0.21,0.51) | Very lowb, c,d |
| OD vs. UBE | NA | 0.11(-1.05,1.26) | Very lowb, c,d | 0.11(-1.05,1.26) | Very lowb, c,d | |
| OD vs. EDF | 0.09(-0.92,0.41) | Very lowb, c,d | 0.27(-0.54,1.09) | Very lowb, c,d | 0.20(-0.41,0.82) | Very lowb, c,d |
| OD vs. ODF | NA | 0.05(-0.82,0.91) | Very lowb, c,d | 0.05(-0.82,0.91) | Very lowb, c,d | |
| MD vs. PED | 0.06(-0.29,0.41) | Lowb, c | 0.34(-0.26,0.94) | Very lowb, c,d | 0.13(-0.17,0.43) | Very lowb, c,d |
| MD vs. UBE | 0.08(-1.01,1.16) | Lowb, c | NA | 0.08(-1.01,1.17) | Lowb, c | |
| MD vs. EDF | 0.35(-0.66.1.36) | Lowb, c | 0.07(-0.72,0.87) | Very lowb, c,d | 0.18(-0.43,0.78) | Very lowb, c,d |
| MD vs. ODF | NA | 0.24(-0.96,1.44) | Very lowb, c,d | 0.24(-0.96,1.44) | Very lowb, c,d | |
| PED vs. UBE | NA | 0.05(-1.08,1.18) | Very lowb, c,d | 0.05(-1.08,1.18) | Very lowb, c,d | |
| PED vs. EDF | -0.01(-1.04,1.01) | Lowb, c | 0.08(-0.70,0.86) | Very lowb, c,d | 0.05(-0.55,0.65) | Very lowb, c,d |
| PED vs. ODF | 0.09(-1.06,1.24) | Lowb, c | -0.5(-1.70,0.70) | Very lowb, c,d | 0.20(-0.60,-1.01) | Very lowb, c,d |
| UBE vs. EDF | NA | 0.09(-1.15,1.34) | Very lowb, c,d | 0.09(-1.15,1.34) | Very lowb, c,d | |
| UBE vs. ODF | NA | 0.16(-1.20,1.15) | Very lowb, c,d | 0.16(-1.20,1.15) | Very lowb, c,d | |
| EDF vs. ODF | NA | 0.25(-0.73,1.23) | Very lowb, c,d | 0.25(-0.73,1.23) | Very lowb, c,d | |
Disability score
Twenty-six studies with 4552 patients provided usable results for the ODI. The NMA results of the ODI are very similar to those of the VAS. EDF (SMD − 0.23; 95% CI -0.39, -0.06), PED (SMD − 0.21; 95% CI -0.35, -0.07), MD (SMD − 0.19; 95% CI -0.33, -0.06) and OD (SMD − 0.17; 95% CI -0.29, -0.04) were significantly different from conservative treatment (Fig. 4B), which was beneficial for functional recovery. UBE and ODF outperformed conservative treatment, although the difference was not statistically significant. The SUCRA plot (Supplementary Fig. 2A) provided support for these findings and showed a very similar trend with the league chart (Supplementary Fig. 2B), in which EDF (SUCRA value = 77.3), PED (72.8), and MD (60.6) ranked in the top three, while ODF (40.7) and conservative treatment (3.8) ranked in the last two. Although the ranking orders of UBE and OD were swapped, their functional recovery effects and SUCRA values were extremely similar. Additionally, most results were of low or very low certainty of evidence (Table 3B).
Table 3B.
Effect estimates and grading of recommendations, assessment, development, and evaluations quality ratings for comparison of different interventions for disability score
| Comparison | Direct evidence | Indirect evidence | Network meta-analysis | |||
|---|---|---|---|---|---|---|
| SMD(95% CI)a | Certainty | SMD(95% CI) a | Certainty | SMD(95% CI) a | Certainty | |
| Cons vs. OD | *0.21(0.06,0.36) | Moderateb | 0.06(-0.18,0.30) | Very lowb, c,d | *0.17(0.04,0.29) | Very lowb, c,d |
| Cons vs. MD | 0.10(-0.12,0.33) | Lowb, c | *0.24(0.07,0.41) | Very lowb, c,d | *0.19(0.06,0.33) | Very lowb, c,d |
| Cons vs. PED | NA | *0.21(0.07,0.35) | Lowb, d | *0.21(0.07,0.35) | Lowb, d | |
| Cons vs. UBE | NA | 0.15(-0.13,0.44) | Very lowb, c,d | 0.15(-0.13,0.44) | Very lowb, c,d | |
| Cons vs. EDF | NA | 0.15(-0.13,0.44) | Very lowb, c,d | *0.23(-0.06,0.39) | Very lowb, c,d | |
| Cons vs. ODF | NA | 0.15(-0.13,0.44) | Very lowb, c,d | 0.14(-0.06,0.25) | Very lowb, c,d | |
| OD vs. MD | 0.03(-0.11,0.16) | Very lowb, c,d | 0.02(-0.09,0.13) | Very lowb, c,d | 0.02(-0.06,0.11) | Very lowb, c,d |
| OD vs. PED | 0.08(-0.04,0.20) | Lowb, c | 0.01(-0.12,0.12) | Very lowb, c,d | 0.04(-0.04,0.12) | Very lowb, c,d |
| OD vs. UBE | NA | -0.01(-0.28,0.25) | Very lowb, c,d | -0.01(-0.28,0.25) | Very lowb, c,d | |
| OD vs. EDF | 0.02(-0.18,0.21) | Very lowb, c,d | 0.09(-0.07,0.25) | Very lowb, c,d | 0.06(-0.06,0.18) | Very lowb, c,d |
| OD vs. ODF | NA | 0.02(-0.15,0.20) | Very lowb, c,d | 0.02(-0.15,0.20) | Very lowb, c,d | |
| MD vs. PED | 0.01(-0.07,0.07) | Lowb, c | 0.08(-0.05,0.21) | Very lowb, c,d | 0.02(-0.04,0.08) | Very lowb, c,d |
| MD vs. UBE | -0.04(-0.29,0.21) | Lowb, c | NA | 0.04(-0.21,0.29) | Lowb, c | |
| MD vs. EDF | 0.09(-0.11,0.29) | Lowb, c | 0.01(-0.15,0.15) | Very lowb, c,d | 0.03(-0.08,0.15) | Very lowb, c,d |
| MD vs. ODF | 0.06(-0.22,0.34) | Very lowb, c,d | 0.06(-0.22,0.34) | Very lowb, c,d | ||
| PED vs. UBE | NA | 0.06(-0.20,0.31) | Very lowb, c,d | 0.06(-0.20,0.31) | Very lowb, c,d | |
| PED vs. EDF | 0.01(-0.19,0.20) | Lowb, c | 0.03(-0.13,0.19) | Very lowb, c,d | 0.02(-0.10,0.13) | Very lowb, c,d |
| PED vs. ODF | 0.08(-0.19,0.35) | Lowb, c | 0.06(0.14,0.26) | Very lowb, c,d | 0.07(-0.09,0.23) | Very lowb, c,d |
| UBE vs. EDF | NA | 0.07(-0.20,0.35) | Very lowb, c,d | 0.07(-0.20,0.35) | Very lowb, c,d | |
| UBE vs. ODF | NA | 0.01(-0.28,0.31) | Very lowb, c,d | 0.01(-0.28,0.31) | Very lowb, c,d | |
| EDF vs. ODF | NA | 0.08(-0.11,0.27) | Very lowb, c,d | 0.08(-0.11,0.27) | Very lowb, c,d | |
Recurrence rate
Seventeen studies with 3216 patients provided usable results for recurrence. There were no significant differences in recurrence rates across all comparisons (Fig.5B), but EDF (SUCRA value = 74.0) and ODF (68.9) tended to perform best, ranking highest in the SUCRA plot (Supplementary Fig. 3A). In the league chart (Supplementary Fig. 3B), the comparison between Cons and EDF/ODF yielded high RRs; however, these values were not statistically significant and were based solely on indirect evidence. Additionally, Table 3C shows that most of the results were of low and very low certainty of evidence.
Table 3C.
Effect estimates and grading of recommendations, assessment, development, and evaluations quality ratings for comparison of different interventions for recurrence rate
| Comparison | Direct evidence | Indirect evidence | Network meta-analysis | |||
|---|---|---|---|---|---|---|
| RR(95% CI)a | Certainty | RR(95% CI) a | Certainty | RR(95% CI) a | Certainty | |
| OD vs. Cons | NA | 0.26(0.04,1.66) | Lowb, c | 0.26(0.04,1.66) | Lowb, c | |
| MD vs. Cons | 0.26(0.06,1.23) | Lowb, c | NA | 0.26(0.06,1.23) | Lowb, c | |
| PED vs. Cons | NA | 0.38(0.07,1.93) | Lowb, c | 0.38(0.07,1.93) | Lowb, c | |
| UBE vs. Cons | NA | 0.26(0.01,17.9) | Very lowb, c,d | 0.26(0.01,17.9) | Very lowb, c,d | |
| EDF vs. Cons | NA | 0.20(0.04,1.02) | Lowb, c | 0.20(0.04,1.02) | Lowb, c | |
| ODF vs. Cons | NA | 0.13(0.01,4.57) | Lowb, c | 0.13(0.01,4.57) | Lowb, c | |
| MD vs. OD | 1.00(0.37,2.73) | Lowb, c | NA | 1.00(0.37,2.73) | Lowb, c | |
| PED vs. OD | NA | 0.69(0.23,2.11) | Lowb, c | 0.69(0.23,2.11) | Lowb, c | |
| UBE vs. OD | NA | 1.00(0.02,57.89) | Very lowb, c,d | 1.00(0.02,57.89) | Very lowb, c,d | |
| EDF vs. OD | NA | 0.75(0.24,2.36) | Lowb, c | 0.75(0.24,2.36) | Lowb, c | |
| ODF vs. OD | NA | 0.48(0.02,14.31) | Lowb, c | 0.48(0.02,14.31) | Lowb, c | |
| PED vs. MD | 1.39(0.84,2.29) | Lowb, c | 6.96(0.33,145.6) | Lowb, c | 1.45(0.88,2.38) | Lowb, c |
| UBE vs. MD | 1.00(0.02,51.54) | Very lowb, c,d | NA | 1.00(0.02,51.54) | Very lowb, c,d | |
| EDF vs. MD | 0.79(0.46,1.36) | Lowb, c | 0.16(0.01,3.05) | Lowb, c | 0.75(0.44,1.30) | Lowb, c |
| ODF vs. MD | NA | 0.48(0.02,12.30) | Lowb, c | 0.48(0.02,12.30) | Lowb, c | |
| UBE vs. PED | NA | 0.69(0.01,36.33) | Very lowb, c,d | 0.69(0.01,36.33) | Very lowb, c,d | |
| EDF vs. PED | 0.11(0.01,1.70) | Lowb, c | 0.57(0.28,1.18) | Lowb, c | 0.52(0.25,1.07) | Lowb, c |
| ODF vs. PED | 0.33(0.01,8.16) | Lowb, c | NA | 0.33(0.01,8.16) | Lowb, c | |
| EDF vs. UBE | NA | 0.75(0.01,39.97) | Very lowb, c,d | 0.75(0.01,39.97) | Very lowb, c,d | |
| ODF vs. UBE | NA | 0.48(0.01,78.73) | Very lowb, c,d | 0.48(0.01,78.73) | Very lowb, c,d | |
| ODF vs. EDF | NA | 1.56(0.06,41.45) | Lowb, c | 1.56(0.06,41.45) | Lowb, c | |
Abbreviations: Cons = Conservative treatment; OD = Open discectomy; MD = Microdiscectomy; PED = Percutaneous endoscopic discectomy, unilateral single-channel; UBE = Unilateral biportal endoscopic discectomy, unilateral double-channel; EDF = Endoscopic discectomy with internal fixation; ODF = Open discectomy with internal fixation. a Data are at the final follow-up or one-year follow-up. Values below 0 indicate that the treatment mentioned first (before the vs) is favored, whereas values above 0 indicate that the treatment mentioned (after the vs) is favored in Table 3A and Table 3B. Values below 1 indicate that the treatment mentioned first (before the vs) is favored, whereas values above 1 indicate that the treatment mentioned (after the vs) is favored in Table 3C. b Refers to indirectness. c Refers to imprecision. d Refers to risk of bias. * Refers to statistical significance
Discussion
Due to the development of surgical endoscopy technology and internal fixation materials, LDH treatments have expanded beyond conservative treatment and traditional operations. UBE is a new minimally invasive discectomy technique that has gradually emerged from Asia in recent years. The double channel enables real-time visualization and surgical operation simultaneously, thereby effectively alleviating the limitations of removing the lumbar lamina via single-channel endoscopy. Furthermore, the emergence of EDF is beneficial for patients to maintain the integrity of the paravertebral muscles while reconstructing the biomechanical stability of the lumbar spine. According to the author’s observations in clinical practice, UBE and EDF are associated with less trauma, better therapeutic effects and acceptance for patients. Therefore, it should have excellent application prospects. However, the development history of UBE is short, and its safety and efficacy have not yet been tested over time. Therefore, this seems to have produced an interesting phenomenon. Senior surgeons prefer PED and traditional operations, whereas young surgeons prefer UBE and EDF. This highlights the need for rigorous studies to compare various treatment strategies, including emerging methods. NMA offers a comprehensive approach for simultaneously comparing multiple interventions on a broader statistical basis. This NMA was conducted to address the unclear definition of the overall efficacy and safety of different LDH treatments.
The NMA results demonstrated that EDF, PED, MD and OD were significantly superior to conservative treatment in terms of relieving postoperative pain. This finding was clinically important because pain is most patients’ first symptom, and pain relief is their primary concern. Therefore, surgery is still recommended for patients with persistent symptoms, despite the possibility of symptomatic relief with conservative treatment. Among these LDH treatments, the NMA results and SUCRA plot showed the same trend, in which EDF and PED yielded the 2 best therapeutic effects and were the most recommended. However, Wei et al. [44] reported that the pain relief associated with percutaneous discectomy was significantly worse than that associated with other surgical approaches. This difference may be caused by different classifications of surgical methods, and the authors did not elaborate the criteria of various classifications in the article. In fact, the surgical classification of LDH is often unclear and confusing in many papers. To clarify this problem, Table 1 shows our recommended classification criteria: non-endoscopic surgeries were classified as OD and MD based on incision size and whether a microscope was used; endoscopic surgeries were categorized as PED and UBE based on approach number; and surgeries involving internal fixation were divided into EDF and ODF based on whether an endoscope was used. Additionally, our results were consistent with those of a recent meta-analysis [13, 45]– [46] that supported the use of the EDF and PED for enhancing pain relief. Previous studies [47]– [48] reported the superiority of endoscopic surgery but did not include endoscopic fixation or separately examine this technique in subgroup analysis. The improved integration of minimally invasive techniques with internal fixation devices over the years may account for this difference. Notably, UBE (SMD − 0.89; 95% CI -1.61, 0.26) and PED (SMD − 0.89; 95% CI -2.16, 0.39) have therapeutic effects and recommendation rankings similar to those of conservative treatment, but UBE has no statistical significance. This might be due to the limited number of RCTs and sample sizes for UBE. Therefore, more UBE studies should be performed in the future to further verify its reliability and safety.
The second outcome, disability, was roughly similar to the first pain score. The NMA results demonstrated that EDF, PED, MD and OD were significantly superior to conservative treatment in disability recovery. Moreover, the SUCRA plot shows a trend almost identical to that of the NMA results. The above results verify that LDH patients can benefit from surgery, which is conducive to the rehabilitation of waist and lower limb activity. From a clinical perspective, this is taken for granted. The herniated disc compresses the nerve roots, causing corresponding pain symptoms. Prolonged compression may even cause sensory paralysis and motor disorders in corresponding areas, which further lead to quality of life impairments. Surgical interventions remove the protruding intervertebral disc and loosen the nerve root, which is beneficial for neurological function recovery. However, the types of trauma caused by different surgical methods vary. Will this have an impact on disability recovery again? Pairwise comparisons of the remaining surgical methods revealed no significant differences in these NMA results. In other words, the implantation of internal fixation devices did not significantly affect patients’ quality of life, which helps alleviate patients’ concerns about implants. Although the degree of trauma associated with implant surgery is greater than that associated with non-implant surgery, it can restore posterior spine chain stability to a certain extent, and this advantage is further magnified in EDF. This might be the reason why internal fixation devices have no impact on disability recovery. However, this conclusion is only based on a one-year follow-up. The longer-term effects of implant surgery still need to be verified.
Recurrence rates serve as an important objective index for patients and surgeons. It directly assesses the clinical efficacy for patients and helps surgeons make informed treatment decisions and optimize surgical techniques. Additionally, postoperative recurrence represents a heavy emotional and physical blow and a loss of trust in the doctor for patients. It is generally expected that conservative management would be less effective than surgery, but we found no difference in the recurrence rate for any comparisons. The results were also consistent with those of a previous NMA [13, 44]. However, the SUCRA plot showed the advantages of EDF and ODF. This can be understood from a clinical point of view because the internal fixation device was installed after the disc was cleared, which strengthened the stability between the lumbar vertebrae and thus reduced the risk of recurrence. Additionally, several studies have explored the effects of different internal fixation techniques in the treatment of lumbar degenerative diseases [49–51]. We were unable to conduct subgroup analyses based on internal fixation materials because of the limited number of articles included. If possible, future research could benefit from further exploration and refinement in this area.
Although we conducted an extensive literature search, incorporated high-quality studies, and performed a rigorous statistical analysis, there were several limitations in this study. First, the included studies varied in follow-up duration, with most outcomes occurring after one year, which may have impacted the consistency of the results. An NMA with longer follow-up periods could be performed in the future. Second, in previous RCTs, it remains unclear whether reoperations were due to recurrence at the original surgical segment or the other segments. Therefore, we cannot definitively attribute the varied reoperation rates to surgical interventions. Third, since some of the subgroups consisted of only a few studies, imprecise results might be obtained. Further imprecision is possible, as some NMA results were based only on indirect comparisons. Finally, the use of implants or new technologies can be costly; therefore, a similar cost‒benefit analysis [52] is needed to guide decision-making, which is also beyond the scope of this article.
Conclusion
There were no statistically significant differences in recurrence among the interventions. All surgical treatments outperformed conservative treatment in terms of pain relief and disability recovery, and EDF showed the best performance. The implantation of internal fixation devices has no impact on patient quality of life. EDF appears highly effective, but other less invasive options, such as PED, have similarly good outcomes in many respects.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Acknowledgements
Not applicable.
Author contributions
Conception and design: W.W. and K.S. Literature retrieval and inclusion: M.Z., S.C., Y.W. and J.L. Data measurement and analysis: K.S. Drafting the article: K.S. Critically revising the article: W.W. Reviewed final version of the manuscript and approved it for submission: all authors. Study supervision: W.W. guarantor of the review: W.W.
Funding
The study was supported by Natural Science Foundation of Hubei province (2023AFB1006) and Hubei Provincial Health Commission Young Talent Program (WJ2023Q020).
Data availability
All data generated or analyzed during this study are included in this published article.
Declarations
Ethics approval
Not applicable. All included study adhered to the ethical principles outlined in the Declaration of Helsinki.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Data Availability Statement
All data generated or analyzed during this study are included in this published article.