Table.
GRADE evaluation of interventions for herniated lumbar disc
| Important outcomes | Pain, functional improvement, mobility, patient perception of improvement, quality of life, adverse effects | ||||||||
| Number of studies (participants) | Outcome | Comparison | Type of evidence | Quality | Consistency | Directness | Effect size | GRADE | Comment |
| What are the effects of drug treatments for herniated lumbar disc? | |||||||||
| 4 (380) | Pain | Epidural corticosteroids v no epidural corticosteroids | 4 | –2 | –1 | 0 | 0 | Very low | Quality points deducted for incomplete reporting of results, and for not reporting method of randomisation. Consistency point deducted for different outcomes at different endpoints |
| 4 (380) | Functional improvement | Epidural corticosteroids v no epidural corticosteroids | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for incomplete reporting of results, and for not reporting method of randomisation |
| 5(645) | Patient perception of improvement | Epidural corticosteroids v no epidural corticosteroids | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for incomplete reporting of results, and for not reporting method of randomisation. Directness point deducted for not defining outcome measured |
| 1 (36) | Pain | Epidural corticosteroid plus conservative non-operative treatment v conservative treatment only | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for wide range of interventions used in comparison |
| 1 (36) | Mobility | Epidural corticosteroid plus conservative non-operative treatment v conservative treatment only | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for wide range of interventions used in comparison |
| 1 (100) | Pain | Epidural corticosteroid v standard discectomy | 4 | –3 | –1 | 0 | 0 | Very low | Quality points deducted for sparse data and methodological flaws (incomplete reporting of results, lack of blinding). Consistency point deducted for different results at different endpoints |
| 1 (100) | Functional improvement | Epidural corticosteroid v standard discectomy | 4 | –3 | –1 | 0 | 0 | Very low | Quality points deducted for sparse data and methodological flaws (incomplete reporting of results, lack of blinding). Consistency point deducted for different results at different endpoints |
| 1 (41) | Pain | Infliximab v placebo | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 1 (41) | Functional improvement | Infliximab v placebo | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 3 (321) | Pain | NSAIDs v placebo | 4 | 0 | 0 | –2 | 0 | Low | Directness points deducted for few comparators and for differences in outcomes measured |
| 1 (40) | Pain | NSAIDs v electroacupuncture | 4 | –2 | 0 | –2 | 0 | Very low | Quality points deducted for sparse data and for not reporting method of randomisation. Directness points deducted for possible inclusion of people without disc herniation, and uncertainty about generalisability of outcomes measured |
| 1 (40) | Functional improvement | NSAIDs v electroacupuncture | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data, and for not reporting method of randomisation. Directness point deducted for possible inclusion of people without disc herniation. |
| What are the effects of non-drug treatments for herniated lumbar disc? | |||||||||
| 1 (102) | Pain | Spinal manipulation v placebo or sham treatment | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 1 (102) | Quality of life | Spinal manipulation v placebo or sham treatment | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data, and for incomplete reporting of results |
| 1 (233) | Patient perception of improvement | Spinal manipulation v heat | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for incomplete reporting of results, and methodological flaws (not reporting method of randomisation, group baseline characteristics, uncertainty about intention-to-treat analysis, poor follow-up) and uncertainty about groups receiving equal number of treatments |
| 1 (322) | Pain | Spinal manipulation v exercise therapy | 4 | –3 | 0 | –1 | 0 | Very low | Quality points deducted for incomplete reporting of results, and methodological flaws (not reporting method of randomisation, group baseline characteristics, uncertainty about blinding). Directness point deducted for inclusion of people without herniated disc |
| 1 (322) | Patient perception of improvement | Spinal manipulation v exercise therapy | 4 | –3 | 0 | –1 | 0 | Very low | Quality points deducted for incomplete reporting of results, and methodological flaws (not reporting method of randomisation, group baseline characteristics, uncertainty about blinding). Directness point deducted for inclusion of people without herniated disc |
| 1 (322) | Patient perception of improvement | Spinal manipulation v traction | 4 | –3 | 0 | –1 | 0 | Very low | Quality points deducted for incomplete reporting of results, and methodological flaws (not reporting method of randomisation, group baseline characteristics, uncertainty about blinding). Directness point deducted for inclusion of people without herniated disc |
| 1 (112) | Pain | Spinal manipulation v traction | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and for uncertainty about endpoint |
| 1 (112) | Functional improvement | Spinal manipulation v traction | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and for uncertainty about endpoint |
| 1 (42) | Pain | Laser acupuncture v sham laser acupuncture | 4 | –2 | 0 | –2 | 0 | Very low | Quality points deducted for sparse data, and incomplete reporting of results. Directness points deducted for inclusion of people without disc herniation |
| 1 (30) | Pain | Acupuncture v sham acupuncture | 4 | –2 | 0 | –2 | 0 | Very low | Quality points deducted for sparse data, and incomplete reporting of results. Directness points deducted for inclusion of people without disc herniation, and for conflicting results about benefits of outcomes measured |
| 1(58) | Pain | Adding acupuncture to manipulation v manipulation alone | 4 | –3 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data, not reporting method of randomisation and for unspecified follow-up time. Directness point deducted for no long-term results |
| 2 (372) | Pain | Exercise therapy v traction | 4 | –3 | 0 | –1 | 0 | Very low | Quality points deducted for incomplete reporting of results, no long-term results, and methodological flaws (not reporting method of randomisation, group baseline characteristics, uncertainty about blinding). Directness point deducted for inclusion of people without herniated disc |
| 1 (50) | Functional improvement | Exercise therapy v traction | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and no long-term results |
| 1 (322) | Patient perception of improvement | Exercise therapy v traction | 4 | –3 | 0 | –1 | 0 | Very low | Quality points deducted for incomplete reporting of results, and methodological flaws (not reporting method of randomisation, group baseline characteristics, uncertainty about blinding). Directness point deducted for inclusion of people without herniated disc |
| 1 (40) | Functional improvement | Adding exercise plus education to conventional non-surgical treatment v conventional non-surgical treatment alone | 4 | –1 | –1 | 0 | 0 | Low | Quality point deducted for sparse data. Consistency point deducted for conflicting results on analysis |
| 1 (110) | Pain | Massage/manipulation v massage/manipulation plus functional training exercises v traction | 4 | –1 | 0 | –2 | 0 | Very low | Quality point deducted for sparse data. Directness points deducted for unclear measurement of outcomes, and for including spinal massage techniques (uncertainty about generalisability of results with other massage-only interventions) |
| 1 (110) | Functional improvement | Massage/manipulation v massage/manipulation plus functional training exercises v traction | 4 | –1 | 0 | –2 | 0 | Very low | Quality point deducted for sparse data. Directness points deducted for unclear measurement of outcomes, and for including spinal massage techniques (uncertainty about generalisability of results with other massage-only interventions) |
| 1 (183) | Pain | Bed rest v no treatment | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for uncertainty about generalisability of results for people with herniated lumbar disc |
| 1 (183) | Functional improvement | Bed rest v no treatment | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for uncertainty about generalisability of results for people with herniated lumbar disc |
| 1 (183) | Patient perception of improvement | Bed rest v no treatment | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for uncertainty about generalisability of results for people with herniated lumbar disc |
| 4 (329) | Pain | Traction v no traction or sham traction | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting of results. Directness point deducted for inclusion of people without disc herniation |
| 5 (431) | Functional improvement | Traction v no traction or sham traction | 4 | –1 | 0 | –2 | 0 | Very low | Quality point deducted for incomplete reporting of results. Directness points deducted for inclusion of people without disc herniation and for inclusion of other interventions |
| 1 (102) | Patient perception of improvement | Traction v no traction or sham traction | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for inclusion of other interventions |
| 2 (93) | Functional improvement | Autotraction v passive traction | 4 | –3 | –1 | –1 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and no intention-to-treat analysis. Consistency point deducted for conflicting results. Directness point deducted for assessing different outcomes |
| What are the effects of surgery for herniated lumbar disc? | |||||||||
| 2 (339) | Pain | Microdiscectomy v conservative treatment | 4 | –1 | –1 | –1 | 0 | Very low | Quality point deducted for methodological flaw (high crossover between interventions). Consistency point deducted for different results at different endpoints. Directness point deducted for multiple interventions in comparison. |
| 2 (339) | Functional improvement | Microdiscectomy v conservative treatment | 4 | –1 | –1 | –1 | 0 | Very low | Quality point deducted for methodological flaw (high crossover between interventions). Consistency point deducted for different results at different endpoints. Directness point deducted for multiple interventions in comparison. |
| 1 (56) | Quality of life | Microdiscectomy v conservative treatment | 4 | –1 | 0 | –1 | 0 | Low | Quality points deducted for sparse data. Directness point deducted for multiple interventions in comparison. |
| 1 (283) | Patient perception of improvement | Microdiscectomy v conservative treatment | 4 | –1 | –1 | –1 | 0 | Very low | Quality point deducted for methodological flaw (high crossover between interventions). Consistency point deducted for different results at different endpoints. Directness point deducted for multiple interventions in comparison. |
| 1 (60) | Pain | Video-assisted arthroscopic microdiscectomy v standard discectomy | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data, and incomplete reporting of results |
| 1 (60) | Patient perception of improvement | Video-assisted arthroscopic microdiscectomy v standard discectomy | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 2 (627) | Pain | Standard discectomy v conservative treatment | 4 | 0 | –2 | 0 | 0 | Low | Consistency points deducted for conflicting results and different results at different endpoints |
| 2 (627) | Functional improvement | Standard discectomy v conservative treatment | 4 | 0 | –2 | 0 | 0 | Low | Consistency points deducted for conflicting results, and different results at different endpoints |
| 1 (60) | Patient perception of improvement | Standard discectomy v microdiscectomy | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 5 (378) | Pain | Standard discectomy v microdiscectomy | 4 | –1 | 0 | –2 | 0 | Very low | Quality point deducted for incomplete reporting of results. Directness points deducted for uncertainty about outcomes in one study, and for uncertainty about baseline differences in another study |
Type of evidence: 4 = RCT; 2 = ObservationalConsistency: similarity of results across studies Directness: generalisability of population or outcomes Effect size: based on relative risk or odds ratio