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BMJ Clinical Evidence logoLink to BMJ Clinical Evidence
. 2011 Jun 28;2011:1118.

Herniated lumbar disc

Joanne L Jordan 1,#, Kika Konstantinou 2,#, John O'Dowd 3,#
PMCID: PMC3275148  PMID: 21711958

Abstract

Introduction

Herniated lumbar disc is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space. The highest prevalence is among people aged 30 to 50 years, with a male to female ratio of 2:1. There is little evidence to suggest that drug treatments are effective in treating herniated disc.

Methods and outcomes

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of drug treatments, non-drug treatments, and surgery for herniated lumbar disc? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

Results

We found 37 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

Conclusions

In this systematic review, we present information relating to the effectiveness and safety of the following interventions: acupuncture, advice to stay active, analgesics, antidepressants, bed rest, corticosteroids (epidural injections), cytokine inhibitors (infliximab), discectomy (automated percutaneous, laser, microdiscectomy, standard), exercise therapy, heat, ice, massage, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), percutaneous disc decompression, spinal manipulation, and traction.

Key Points

Herniated lumbar disc is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space.

  • The highest prevalence is among people aged 30 to 50 years, with a male to female ratio of 2:1.

There is little high-quality evidence to suggest that drug treatments are effective in treating herniated disc.

With regard to non-drug treatments, spinal manipulation seems more effective at relieving local or radiating pain in people with acute back pain and sciatica with disc protrusion compared with sham manipulation, although concerns exist regarding possible further herniation from spinal manipulation in people who are surgical candidates.

About 10% of people have sufficient pain after 6 weeks for surgery to become a consideration.

Clinical context

About this condition

Definition

Herniated lumbar disc is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space.[1] The diagnosis can be confirmed by radiological examination. However, MRI findings of herniated disc are not always accompanied by clinical symptoms.[2] [3] This review covers treatment of people with clinical symptoms relating to confirmed or suspected disc herniation. It does not include treatment of people with spinal cord compression, or people with cauda equina syndrome, which require emergency intervention. The management of non-specific acute low back pain and chronic low back pain are covered elsewhere in Clinical Evidence.

Incidence/ Prevalence

The prevalence of symptomatic herniated lumbar disc is about 1% to 3% in Finland and Italy, depending on age and sex.[4] The highest prevalence is among people aged 30 to 50 years,[5] with a male to female ratio of 2:1.[6] In people aged 25 to 55 years, about 95% of herniated discs occur at the lower lumbar spine (L4/5 and L5/S1 level); disc herniation above this level is more common in people aged over 55 years.[7] [8]

Aetiology/ Risk factors

Radiographical evidence of disc herniation does not reliably predict low back pain in the future, or correlate with symptoms; 19% to 27% of people without symptoms have disc herniation on imaging.[2] [9] Risk factors for disc herniation include smoking (OR 1.7, 95% CI 1.0 to 2.5), weight-bearing sports (e.g., weight lifting, hammer throw), and certain work activities, such as repeated lifting. Driving a motor vehicle has been suggested to be a risk factor for disc herniation, although evidence is inconclusive (OR 1.7, 95% CI 0.2 to 2.7).[6] [10] [11]

Prognosis

The natural history of disc herniation is difficult to determine, because most people take some form of treatment for their back pain, and a formal diagnosis is not always made.[6] Clinical improvement is usual in most people, and only about 10% of people still have sufficient pain after 6 weeks to consider surgery. Sequential MRIs have shown that the herniated portion of the disc tends to regress over time, with partial to complete resolution after 6 months in two-thirds of people.[12]

Aims of intervention

To relieve pain; increase mobility and function; improve quality of life; and minimise adverse effects of treatments.

Outcomes

Primary outcomes: pain, including global symptom relief; functional improvement; patient perception of improvement; quality of life; and adverse effects of treatment. Secondary outcomes: return to work; use of analgesia; and duration of hospital admission.

Methods

Clinical Evidence search and appraisal June 2010. The following databases were used to identify studies for this systematic review: Medline 1966 to June 2010, Embase 1980 to June 2010, and The Cochrane Database of Systematic Reviews, May 2010 (online; 1966 to date of issue). An additional search within The Cochrane Library was carried out for the Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA). We also searched for retractions of studies included in the review. Abstracts of the studies retrieved from the initial search were assessed by an information specialist. Selected studies were then sent to the contributor for additional assessment, using predetermined criteria to identify relevant studies. Study design criteria for inclusion in this review were: published systematic reviews of RCTs and RCTs in any language, at least single blinded, and containing >20 people of whom >80% were followed up. There was no minimum length of follow-up required to include trials. We excluded all trials described as "open", "open label", or not blinded unless blinding was impossible. We included systematic reviews of RCTs and RCTs where harms of an included intervention were studied applying the same study design criteria for inclusion as we did for benefits. In addition we use a regular surveillance protocol to capture harms alerts from organisations such as the FDA and the MHRA, which are added to the reviews as required. The contributors used confidence interval analysis[13] and chi-square test analysis from PEPI version 4.0[14] in their own calculations, which are presented in the review. To aid readability of the numerical data in our reviews, we round many percentages to the nearest whole number. Readers should be aware of this when relating percentages to summary statistics such as relative risks (RRs) and odds ratios (ORs). We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table). The categorisation of the quality of the evidence (high, moderate, low, or very low) reflects the quality of evidence available for our chosen outcomes in our defined populations of interest. These categorisations are not necessarily a reflection of the overall methodological quality of any individual study, because the Clinical Evidence population and outcome of choice may represent only a small subset of the total outcomes reported, and population included, in any individual trial. For further details of how we perform the GRADE evaluation and the scoring system we use, please see our website (www.clinicalevidence.com).

Table.

GRADE Evaluation of interventions for Herniated lumbar disc.

Important outcomes Functional improvement, Need for surgery, Pain, Patient perception of improvement, Quality of life
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?
8 (705) Pain Epidural corticosteroid injections versus no epidural corticosteroid injection 4 –1 –1 0 0 Low Quality point deducted for incomplete reporting of results. Consistency point deducted for different results at different end points
4 (386) Functional improvement Epidural corticosteroid injections versus no epidural corticosteroid injection 4 –1 0 0 0 Moderate Quality point deducted for incomplete reporting of results
2 (417) Patient perception of improvement Epidural corticosteroid injections versus no epidural corticosteroid injection 4 0 –1 –1 0 Low Consistency point deducted for different results at different end points. Directness point deducted for not defining outcome measured
2 (213) Need for surgery Epidural corticosteroid injections versus no epidural corticosteroid injection 4 –1 –1 –1 0 Very low Quality point deducted for sparse data. Consistency point deducted conflicting results among trials. Directness point deducted for narrow included population
1 (36) Pain Epidural corticosteroid plus conservative non-operative treatment versus conservative treatment alone 4 –1 0 –1 0 Low Quality point deducted for sparse data. Directness point deducted for wide range of interventions used in comparison, making the results difficult to apply in clinical practice
1 (36) Functional improvement Epidural corticosteroid plus conservative non-operative treatment versus conservative treatment alone 4 –1 0 –1 0 Low Quality point deducted for sparse data. Directness point deducted for wide range of interventions used in comparison, making the results difficult to apply in clinical practice
1 (36) Need for surgery Epidural corticosteroid plus conservative non-operative treatment versus conservative treatment alone 4 –1 0 –1 0 Low Quality point deducted for sparse data. Directness point deducted for wide range of interventions used in comparison, making the results difficult to apply in clinical practice
1 (100) Pain Epidural corticosteroid injection versus discectomy 4 –2 –1 0 0 Very low Quality points deducted for sparse data and incomplete reporting of results. Consistency point deducted for different results at different end points
1 (100) Functional improvement Epidural corticosteroid injection versus discectomy 4 –2 –1 0 0 Very low Quality points deducted for sparse data and incomplete reporting of results. Consistency point deducted for different results at different end points
1 (41) Pain Infliximab versus placebo 4 –1 0 0 0 Moderate Quality point deducted for sparse data
1 (41) Functional improvement Infliximab versus placebo 4 –2 0 0 0 Low Quality points deducted for sparse data and incomplete reporting of results at 12 weeks
1 (41) Need for surgery Infliximab versus placebo 4 –1 0 0 0 Moderate Quality point deducted for sparse data
3 (321) Pain NSAIDs versus placebo 4 0 0 –2 0 Low Directness points deducted for limited range of NSAIDs assessed and for use of unclear outcome measure in meta-analysis
1 (40) Pain NSAIDs versus electroacupuncture 4 –1 0 –2 0 Very low Quality point deducted for sparse data. Directness points deducted for possible inclusion of people without disc herniation and uncertainty about generalisability of outcomes measured
1 (40) Functional improvement NSAIDs versus electroacupuncture 4 –1 0 –1 0 Low Quality point deducted for sparse data. 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 versus placebo or sham treatment 4 –1 0 0 0 Moderate Quality point deducted for sparse data
1 (102) Functional improvement Spinal manipulation versus 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 versus heat treatment 4 –4 0 0 0 Very low Quality points deducted for incomplete reporting of results and for methodological flaws (not reporting 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 versus exercise therapy 4 –3 0 –1 0 Very low Quality points deducted for incomplete reporting of results and methodological flaws (not reporting group baseline characteristics and uncertainty about blinding). Directness point deducted for inclusion of people without herniated disc
1 (322) Patient perception of improvement Spinal manipulation versus exercise therapy 4 –3 0 –1 0 Very low Quality points deducted for incomplete reporting of results and methodological flaws (not reporting group baseline characteristics, uncertainty about blinding). Directness point deducted for inclusion of people without herniated disc
1 (322) Patient perception of improvement Spinal manipulation versus traction 4 –3 0 –1 0 Very low Quality points deducted for incomplete reporting of results and methodological flaws (not reporting group baseline characteristics and uncertainty about blinding). Directness point deducted for inclusion of people without herniated disc
1 (112) Functional improvement Spinal manipulation versus traction 4 –2 0 0 0 Low Quality points deducted for sparse data and uncertainty about end point
1 (30) Pain Acupuncture versus 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
1 (42) Pain Laser acupuncture versus sham laser acupuncture 4 –1 0 –2 0 Very low Quality point deducted for sparse data. Directness points deducted for no long-term results and for inclusion of a wide population making it unclear whether the data are generalisable to herniated disc
1 (58) Pain Adding acupuncture to manipulation compared with manipulation alone 4 –2 0 –1 0 Very low Quality points deducted for sparse data and for unspecified follow-up time. Directness point deducted for no long-term results
2 (372) Pain Exercise therapy versus traction 4 –2 0 –2 0 Very low Quality points deducted for incomplete reporting of results and lack of blinding in 1 RCT. Directness points deducted for poorly defined outcome measure in 1 RCT and for inclusion of people without herniated disc
1 (40) Functional improvement Adding exercise plus education to conventional non-surgical treatment versus conventional non-surgical treatment alone 4 –1 –1 0 0 Low Quality point deducted for sparse data. Consistency point deducted as result sensitive to different methods of calculation
1 (110) Pain Massage/manipulation versus massage/manipulation plus functional training exercises versus 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 whether results using spinal techniques are comparable with results using other massage techniques)
1 (110) Pain Massage/manipulation versus 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 whether results using spinal techniques are comparable with results using other massage techniques)
1 (183) Pain Bed rest versus no treatment (watchful waiting) 4 –1 0 –1 0 Low Quality point deducted for sparse data. Directness point deducted as results were only in people with sciatica, so there is uncertainty about generalisability of results to people with herniated lumbar disc
1 (183) Functional improvement Bed rest versus no treatment (watchful waiting) 4 –1 0 –1 0 Low Quality point deducted for sparse data. Directness point deducted as results were only in people with sciatica, so there is uncertainty about generalisability of results to people with herniated lumbar disc
1 (183) Patient perception of improvement Bed rest versus no treatment (watchful waiting) 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 (329) Pain Traction versus 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 wide range of traction techniques and comparators
1 (102) Functional improvement Traction versus no traction or sham traction 4 –1 0 –1 0 Low Quality point deducted for sparse data. Directness point deducted for use of co-intervention
1 (102) Patient perception of improvement Traction versus no traction or sham traction 4 –1 0 –1 0 Low Quality point deducted for sparse data. Directness point deducted for use of co-intervention
2 (93) Functional improvement Autotraction versus passive traction 4 –3 –1 0 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, perhaps owing to different measures of outcome used
What are the effects of surgery for herniated lumbar disc?
2 (339) Pain Microdiscectomy versus 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 end points. Directness point deducted for multiple interventions in comparison
2 (339) Functional improvement Microdiscectomy versus 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 end points. Directness point deducted for multiple interventions in comparison
1 (56) Quality of life Microdiscectomy versus conservative treatment 4 –1 0 –1 0 Low Quality point deducted for sparse data. Directness point deducted for multiple interventions in comparison
1 (283) Patient perception of improvement Microdiscectomy versus 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 end points. Directness point deducted for multiple interventions in comparison
1 (60) Pain Video-assisted arthroscopic microdiscectomy versus 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 versus standard discectomy 4 –1 0 –1 0 Low Quality point deducted for sparse data. Directness point deducted for unclear outcome measure
2 (627) Pain Standard discectomy versus conservative treatment 4 –1 –1 0 0 Low Quality point deducted for high crossover between treatments. Consistency point deducted for different results at different end points
2 (627) Functional improvement Standard discectomy versus conservative treatment 4 –1 –1 0 0 Low Quality point deducted for high crossover between treatments. Consistency point deducted for different results at different end points
5 (378) Pain Standard discectomy versus microdiscectomy 4 –1 0 –2 0 Very low Quality point deducted for sparse data. Directness points deducted for uncertainty about outcomes in 1 study and for uncertainty about baseline differences in another study
1 (40) Functional improvement Standard discectomy versus microdiscectomy 4 –2 0 0 0 Low Quality points deducted for sparse data and unclear follow-up rate
1 (60) Patient perception of improvement Standard discectomy versus microdiscectomy 4 –1 0 0 0 Moderate Quality point deducted for sparse data
1 (71) Pain Automated percutaneous discectomy versus microdiscectomy 4 –2 0 –1 0 Very low Quality points deducted for sparse data and premature termination of the trial. Directness point deducted for unclear outcome measure
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We initially allocate 4 points to evidence from RCTs, and 2 points to evidence from observational studies. To attain the final GRADE score for a given comparison, points are deducted or added from this initial score based on preset criteria relating to the categories of quality, directness, consistency, and effect size. Quality: based on issues affecting methodological rigour (e.g., incomplete reporting of results, quasi-randomisation, sparse data [<200 people in the analysis]). Consistency: based on similarity of results across studies. Directness: based on generalisability of population or outcomes. Effect size: based on magnitude of effect as measured by statistics such as relative risk, odds ratio, or hazard ratio.

Glossary

Automated percutaneous discectomy

Percutaneous disc decompression using a combined irrigation, suction, and cutting device inserted through a cannula.

Autotraction

The person provides the traction force on the traction table by pulling on the bar on the head of the table while his or her pelvis is held by a girdle and chain to the lower end of the table.

Cauda equina syndrome

Compression of the cauda equina, causing symptoms that include changes in perineal sensation (saddle anaesthesia) and loss of sphincter control. The cauda equina is a collection of spinal roots descending from the lower part of the spinal cord, which occupy the vertebral canal below the spinal cord.

Japanese Orthopaedic Association (JOA) score

This score is for clinical symptoms in people with herniated lumbar disc. Functionality and pain are measured across 4 parameters, on a scale from −6 to +29, with higher scores indicating better outcomes: first, subjective symptoms (0–9 points; low back pain leg pain, tingling gait, or both); second, clinical signs (0–6 points; straight leg raising test sensory disturbance motor disturbance); third, restriction in activities (0–14 points; turn over while lying, standing, washing, leaning forward, sitting for about 1 hour, lifting or holding a heavy object, walking); and fourth, urinary bladder function (–6 points maximum).

Laser discectomy

The surgeon places a laser through a delivery device that has been directed under radiographic control to the disc, and removes the disc material using the laser. It uses many of the same techniques used in automated percutaneous discectomy.

Lasègue's sign

The limitation of straight leg raising in a supine position usually associated with lumbar nerve root compression. Also, in sciatica, added foot dorsiflexion to a straight leg raise results in more pain.

Low-quality evidence

Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Manual traction

A form of passive traction. The person lies supine on a plinth with varying degrees of flexion in the hip and knee joints. The traction force is exerted by the therapist using a belt placed around the therapist's back or hips and attached behind and below the person's knees. The traction force is adjusted by the therapist according to the patient's symptoms, with a maximum force of about 30 kg as measured by a force transducer in the belt.

Microdiscectomy

Removal of protruding disc material, using an operating microscope to guide surgery.

Moderate-quality evidence

Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Oswestry Disability Index

Back-specific, self-reported questionnaire measuring pain and function in completing physical and social activities. The scale score ranges from 0 (no disability) to 100 (maximum disability).

Passive traction

The person lies supine on a traction table with thighs flexed and supported by pillow over knees. The traction force is adjusted manually by the therapist to about 35% of person's body weight, measured by a dynamometer, and then maintained by a chain connection to the foot of the bed. The traction force is adjusted regularly during the treatment session.

Percutaneous disc decompression

Any technique for discectomy performed through percutaneous portals inserted with x-ray control, generally removing intradiscal fragments rather than sequestrated extradiscal fragments.

Roland Morris Disability Questionnaire

A 24-item, self-reported, disability scale specific to back pain recommended for use in primary care and community studies. Measures daily function in completing activities affected by back pain. The scale score ranges from 0 (no disability) to 24 (severe disability).

Short Form (SF)-36

A health-related quality-of-life scale across 8 domains: limitations in physical activities (physical component), limitations in social activities, limitations in usual role activities owing to physical problems, pain, psychological distress and wellbeing (mental health component), limitations in usual role activities because of emotional problems, energy and fatigue, and general health perceptions.

Standard discectomy

Surgical removal, in part or whole, of an intervertebral disc, generally with loop magnification (i.e., eyepieces).

Very low-quality evidence

Any estimate of effect is very uncertain.

Chronic low back pain

Non-specific acute low back pain

Disclaimer

The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients. To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.

Contributor Information

Joanne L Jordan, Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, UK.

Kika Konstantinou, Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, UK.

John O'Dowd, RealHealth Institute, London, UK.

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BMJ Clin Evid. 2011 Jun 28;2011:1118.

Analgesics

Summary

We found no direct information from RCTs about analgesics in the treatment of people with symptomatic herniated lumbar disc.

Benefits and harms

Analgesics:

We found no systematic review or RCTs on the use of analgesics for treatment of people with symptomatic herniated lumbar disc.

Further information on studies

None.

Comment

None.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jun 28;2011:1118.

Antidepressants

Summary

We found no direct information from RCTs about antidepressants in the treatment of people with symptomatic herniated lumbar disc.

Benefits and harms

Antidepressants:

We found no systematic review or RCTs on the use of antidepressants for treatment of people with symptomatic herniated lumbar disc.

Further information on studies

None.

Comment

None.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jun 28;2011:1118.

Corticosteroids (epidural injections)

Summary

We found several RCTs, which assessed a range of different measures of symptom improvement and found inconsistent results, so we are unable to draw conclusions on the effects of epidural injections of corticosteroids.

Benefits and harms

Epidural corticosteroid injections versus no epidural corticosteroid injection:

We found 5 systematic reviews assessing epidural corticosteroid injections in people with radicular pain caused by disc herniation.[15] [16] [17] [18] [19] The first review (search date 1998, 4 RCTs, 332 people) performed a meta-analysis assessing patient perception of improvement, which we report below.[15] The second systematic review (search date 2003, 3 RCTs, none included in the first review, 264 people) did not perform a meta-analysis because of heterogeneity among trial parameters, so we report results from each RCT it identified separately.[16] The third systematic review (search date 2008, 2 RCTs, 80 people) of caudal epidural injections identified one additional RCT not included in previous reviews and did not include a meta-analysis, so we also report this RCT separately.[17] The fourth systematic review (search date 2008, 2 RCTs, 215 people) of transforaminal epidural injections did not find any additional RCTs and did not include a meta-analysis, so we do not report it further.[18] The fifth systematic review (search date 2008, 3 RCTs, 437 people) of lumbar interlaminar epidural injections also did not include a meta-analysis. It included two RCTs identified by the first review but reported on different outcomes and included one further RCT not identified by any of the other reviews, so we report all three RCTs separately.[19] We found one additional RCT not included by any of the reviews[20] and one subsequent RCT, which we also report below.[21]

Pain

Compared with no epidural corticosteroid Epidural corticosteroids may be more effective at improving limb pain at 2 weeks, but may be no more effective after more than 2 weeks in people with disc herniation (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Pain
[16]
Systematic review		 49 people with radiologically confirmed disc herniation
Data from 1 RCT		 Proportion of people with symptom relief 3 months
54% with triamcinolone interlaminar perineural injection
40% with placebo (saline) interlaminar perineural injection plus intramuscular triamcinolone
Absolute numbers not reported
Significance not assessed
Randomisation method not reported
[16]
Systematic review		 160 people with lower-limb pain caused by confirmed disc herniation
Data from 1 RCT		 Proportion of people with symptom relief 12 months
65% with corticosteroid injections
65% with saline placebo injection
Absolute numbers not reported
Reported as not significant
P value not reported 		Not significant
[17]
Systematic review		 23 people with nerve root compromise
Data from 1 RCT		 Proportion of people with improvement in back and leg pain (unspecified) 4 weeks
with caudal corticosteroid injection of 25 mL triamcinolone acetonide 80 mg with or without 0.5% procaine hydrochloride
with placebo (25 mL saline injection)
Absolute results not reported
Reported as significant in favour of corticosteroid injection
No further data reported
[17]
Systematic review		 23 people with nerve root compromise
Data from 1 RCT		 Proportion of people with improvement in back and leg pain (unspecified) 12 months
with caudal corticosteroid injection of 25 mL triamcinolone acetonide 80 mg with or without 0.5% procaine hydrochloride
with placebo (25 mL saline injection)
Absolute results not reported
Reported as no significant difference between groups at 12 months
No further data reported 		Not significant
[19]
Systematic review		 228 people with unilateral sciatica, possibly caused by disc herniation
Data from 1 RCT		 Proportion of people with improvement in leg pain (unspecified) measured by visual analogue scale (VAS) 3 weeks
with triamcinolone 80 mg plus 10 mL bupivacaine 0.25%
with 2 mL normal saline
Absolute results not reported
Reported as no significant difference between groups
No further data reported by review 		Not significant
[19]
Systematic review		 228 people with unilateral sciatica, possibly caused by disc herniation
Data from 1 RCT		 Proportion of people with improvement in leg pain (unspecified) measured by Likert scale 3 weeks
61% with triamcinolone 80 mg plus 10 mL bupivacaine 0.25%
40% with 2 mL normal saline
Absolute numbers not reported
P <0.01 		Effect size not calculated triamcinolone 80 mg plus 10 mL bupivacaine 0.25%
[19]
Systematic review		 228 people with unilateral sciatica, possibly caused by disc herniation
Data from 1 RCT		 Proportion of people with improvement in leg pain (unspecified) measured by VAS 6 weeks
with triamcinolone 80 mg plus 10 mL bupivacaine 0.25%
with 2 mL normal saline
Absolute results not reported
Reported as no significant difference between groups
No further data reported by review 		Not significant
[19]
Systematic review		 228 people with unilateral sciatica, possibly caused by disc herniation
Data from 1 RCT		 Proportion of people with improvement in leg pain (unspecified) measured by Likert scale 6 weeks
with triamcinolone 80 mg plus 10 mL bupivacaine 0.25%
with 2 mL normal saline
Absolute results not reported
Reported as no significant difference between groups
No further data reported by review 		Not significant
[19]
Systematic review		 158 people with sciatica caused by herniated nucleus pulposus
Data from 1 RCT		 Improvement in leg pain (unspecified) 6 weeks
with methylprednisolone acetate (80 mg and 8 mL of isotonic saline)
with 1 mL isotonic saline
Absolute results not reported
P = 0.03 		Effect size not calculated methylprednisolone acetate (80 mg and 8 mL of isotonic saline)
[19]
Systematic review		 158 people with sciatica caused by herniated nucleus pulposus
Data from 1 RCT		 Improvement in leg pain (unspecified) 3 months
with methylprednisolone acetate (80 mg and 8 mL of isotonic saline)
with 1 mL isotonic saline
Absolute results not reported
Reported as no significant differences between groups
No further data reported 		Not significant
[19]
Systematic review		 51 people with lumbar root compression documented by neurological deficit and abnormality noted on myelography
Data from 1 RCT		 Pain (unspecified) 3 months
with 80 mg methylprednisolone (2 mL)
with 2 mL normal saline
Absolute results not reported
Reported as no significant differences between groups
No further data reported 		Not significant
[19]
Systematic review		 151 people with lumbar root compression documented by neurological deficit and abnormality noted on myelography
Data from 1 RCT		 Pain (unspecified) 14 months
with 80 mg methylprednisolone (2 mL)
with 2 mL normal saline
Absolute results not reported
Reported as no significant difference between groups
No further data reported 		Not significant
[20]
RCT		 85 people with sciatica caused by herniated disc Mean change in pain scores from baseline measured by unspecified VAS 35 days
–30.3 mm with epidural corticosteroid injections (2 mL prednisolone acetate at 2-day intervals for a total of 3 injections)
–25.2 mm with placebo (2 mL isotonic saline injection)
Mean difference –5.1
95% CI –18.7 to +8.4 		Not significant
[21]
RCT		 76 people with leg and back pain caused by herniated disc Improvement in leg pain measured by VAS score 3 months
mean change of 27.4 with methylprednisolone 40 mg plus local anaesthetic
mean change of 24.3 with local anaesthetic alone
Significance not assessed
[21]
RCT		 124 people with leg and back pain caused by herniated disc (76 people) or spinal stenosis (48 people) Improvement in back pain measured by VAS score 3 months
mean change of 6.9 with methylprednisolone 40 mg plus local anaesthetic
mean change of 9.9 with local anaesthetic alone
P = 0.57 		Not significant
Open in a new tab

No data from the following reference on this outcome.[15]

Functional improvement

Compared with no epidural corticosteroid Epidural corticosteroids may be no more effective in the longer term at improving disability, as measured by the Roland Morris Disability Questionnaire and Oswestry Disability Index scores, or functional outcomes such as straight leg raising and lumbar flexion, in people with disc herniation (moderate-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Functional improvement
[20]
RCT		 85 people with sciatica caused by herniated disc Roland Morris Disability Questionnaire score (mean change from baseline) 35 days
–5.3 with epidural corticosteroid injections (2 mL prednisolone acetate at 2-day intervals for a total of 3 injections)
–3.2 with placebo (2 mL isotonic saline injection)
ARR –2.1
95% CI –5.0 to +0.8 		Not significant
[19]
Systematic review		 228 people with unilateral sciatica, possibly caused by disc herniation
Data from 1 RCT		 Oswestry Disability Index 3 weeks
with triamcinolone 80 mg plus 10 mL bupivacaine 0.25%
with 2 mL normal saline
Absolute results not reported
Reported as significant difference; see further information on studies
P value not reported 		Effect size not calculated triamcinolone 80 mg plus 10 mL bupivacaine 0.25%
[19]
Systematic review		 228 people with unilateral sciatica, possibly caused by disc herniation
Data from 1 RCT		 Oswestry Disability Index 6 weeks
with triamcinolone 80 mg plus 10 mL bupivacaine 0.25%
with 2 mL normal saline
Absolute results not reported
Reported as no significant difference; see further information on studies
P value not reported 		Not significant
[19]
Systematic review		 158 people with sciatica due to herniated nucleus pulposus
Data from 1 RCT		 Oswestry Disability Index 3 weeks
with methylprednisolone acetate (80 mg and 8 mL of isotonic saline)
with 1 mL isotonic saline
Absolute results not reported
Significance not assessed
[19]
Systematic review		 158 people with sciatica due to herniated nucleus pulposus
Data from 1 RCT		 Oswestry Disability Index 3 months
with methylprednisolone acetate (80 mg and 8 mL of isotonic saline)
with 1 mL isotonic saline
Absolute results not reported
Reported as not significant
No further data reported 		Not significant
[19]
Systematic review		 228 people with unilateral sciatica, possibly caused by disc herniation
Data from 1 RCT		 Oswestry Disability Index 75% improvement in scores 52 weeks
32.5% with triamcinolone 80 mg plus 10 mL bupivacaine 0.25%
29.6% with 2 mL normal saline
Significance not assessed; see further information on studies
[21]
RCT		 76 people with leg and back pain caused by herniated disc Mean change in Oswestry Disability Index 3 months
13.6 with methylprednisolone 40 mg plus local anaesthetic
3.8 with local anaesthetic alone
Significance not assessed
Open in a new tab

No data from the following reference on this outcome.[15] [16] [17]

Patient perception of improvement

Compared with no epidural corticosteroid Epidural corticosteroids may be more effective at increasing subjective global improvement and patient satisfaction in the short term only (2 weeks), but may be no more effective in the longer term (after 2 weeks) in people with disc herniation (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Patient perception of improvement
[15]
Systematic review		 332 people
4 RCTs in this analysis		 Proportion of people with self-perceived global improvement (which was not defined) 2 to 30 days
73/160 (46%) with epidural corticosteroid injections
56/172 (33%) with placebo
OR 2.2
95% CI 1.0 to 4.7 		Not significant
[20]
RCT		 85 people with sciatica caused by herniated disc People rating improvement as "recovery" or "marked improvement" 35 days
21/43 (49%) with epidural corticosteroid injections (2 mL prednisolone acetate at 2-day intervals for a total of 3 injections)
20/42 (48%) with placebo (2 mL isotonic saline injection)
P = 0.91 		Not significant
Open in a new tab

No data from the following reference on this outcome.[16] [19] [17] [21]

Need for surgery

Compared with no epidural corticosteroid We don't know if epidural corticosteroid injection is more effective at reducing the need for surgery in the short term (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Need for surgery
[19]
Systematic review		 158 people with sciatica caused by herniated nucleus pulposus
Data from 1 RCT		 Proportion having back surgery 12 months
26% with methylprednisolone acetate (80 mg and 8 mL of isotonic saline)
25% with 1 mL isotonic saline
Absolute numbers not reported
Reported as not significant
No further data reported 		Not significant
[16]
RCT		 55 people for whom 6 weeks of physiotherapy (undefined), oral use of NSAIDs, and bracing had failed Proportion of people having surgery end of treatment period
8/28 (29%) with transforaminal corticosteroid plus anaesthetic
18/27 (67%) with injections of anaesthetic alone
RR 0.43
95% CI 0.23 to 0.82
NNT 3
95% CI 2 to 6
Contributors' own calculations 		Moderate effect size transforaminal corticosteroid plus anaesthetic
Open in a new tab

No data from the following reference on this outcome.[15] [17] [20] [21]

Adverse effects

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Adverse effects
[15]
Systematic review		 332 people
4 RCTs in this analysis		 Adverse effects 2 to 30 days
with epidural corticosteroid injections
with placebo
Absolute results not reported
[16]
RCT		 264 people
3 RCTs in this analysis		 Adverse effects
with epidural corticosteroid injection
with placebo injection
[20]
RCT		 85 people with sciatica caused by herniated disc Clinically important adverse effects 35 days
2/43 (5%) with epidural corticosteroid injections (2 mL prednisolone acetate at 2-day intervals for a total of 3 injections)
3/42 (7%) with placebo (2 mL isotonic saline injection)
P = 0.68 		Not significant
Open in a new tab

No data from the following reference on this outcome.[17] [19] [21]

Epidural corticosteroid plus conservative non-operative treatment versus conservative treatment alone:

We found one RCT.[22]

Pain

Epidural corticosteroids plus conservative non-operative treatment compared with conservative treatment only Epidural corticosteroids plus conservative non-operative treatment may be no more effective at 6 weeks and 6 months at improving pain scores in people with disc herniation (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Pain
[22]
RCT		 36 people with disc herniation confirmed by MRI Pain scores (visual analogue scale: 0 = no pain, 100  = most pain possible) 6 months
32.9 (range 0–85) with epidural corticosteroid plus conservative non-operative treatment
39.2 (range 0–100) with conservative treatment alone
P = 0.18
The RCT also found no significant difference at 6 weeks 		Not significant
Open in a new tab

Functional improvement

Epidural corticosteroids plus conservative non-operative treatment compared with conservative treatment only Epidural corticosteroids plus conservative non-operative treatment may be no more effective at 6 months at improving mobility scores in people with disc herniation (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Functional improvement
[22]
RCT		 36 people with disc herniation confirmed by MRI Hannover Functional Ability Questionnaire from 0% (lowest mobility) to 100% (highest mobility) 6 months
61.8 (range 25–83) with epidural corticosteroid plus conservative non-operative treatment
57.2 (range 17–83) with conservative treatment alone
P = 0.15 		Not significant
[22]
RCT		 36 people with disc herniation confirmed by MRI People returning to work 6 months
15/17 (88%) with epidural corticosteroid plus conservative non-operative treatment
14/19 (74%) with conservative treatment alone
RR 1.19
95% CI 0.75 to 1.33 		Not significant
Open in a new tab

Need for surgery

Epidural corticosteroids plus conservative non-operative treatment compared with conservative treatment only Epidural corticosteroids plus conservative non-operative treatment may be no more effective at 6 months at reducing the need for surgery (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Need for surgery
[22]
RCT		 36 people with disc herniation confirmed by MRI Proportion of people needing back surgery 6 months
2/17 (12%) with epidural corticosteroid plus conservative non-operative treatment
4/19 (21%) with conservative treatment alone
RR 0.56
95% CI 0.09 to 2.17
Contributors' own calculations
Reported as not significant by original RCT 		Not significant
Open in a new tab

Adverse effects

No data from the following reference on this outcome.[22]

Epidural corticosteroid injection versus discectomy:

We found one systematic review[23] (search date 2007, 1 RCT[24]) comparing epidural injections versus surgery.

Pain

Compared with standard discectomy Epidural corticosteroid injections may be less effective at 1 to 3 months at improving leg pain in people with lumbar disc herniation (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Pain
[24]
RCT		 100 people with lumbar disc herniation >25% of cross-sectional area of spinal canal, who had 6 weeks of unsuccessful non-invasive treatment (physiotherapy, chiropractic treatment, rest, analgesia, or a combination)
In review [23] 		Difference in pain on 11-point visual analogue scale 1 to 3 months
with epidural corticosteroid injections (betamethasone 10–15 mg, 1 week apart up to 3 times until successful)
with discectomy (no further details reported)
Absolute results reported graphically
P = 0.001
The difference between treatments was not sustained at 2 to 3 years' follow-up (results presented graphically; see further information on studies below) 		Effect size not calculated discectomy
Open in a new tab

Functional improvement

Compared with standard discectomy Epidural corticosteroid injections may be less effective at 1 to 3 months at improving Oswestry Disability Index scores in people with lumbar disc herniation (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Functional improvement
[24]
RCT		 100 people with lumbar disc herniation >25% cross-sectional area of spinal canal, who had 6 weeks of unsuccessful non-invasive treatment (physiotherapy, chiropractic treatment, rest, analgesia, or a combination)
In review [23] 		Oswestry Disability Index score 1 to 3 months
with epidural corticosteroid injections (betamethasone 10–15 mg, 1 week apart up to 3 times until successful)
with discectomy (no further details reported)
Absolute results reported graphically
P = 0.015
The difference between treatments was not sustained at 2 to 3 years' follow-up (results presented graphically; see further information on studies below) 		Effect size not calculated discectomy
Open in a new tab

Adverse effects

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Adverse effects
[24]
RCT		 100 people with lumbar disc herniation >25% cross-sectional area of spinal canal, who had 6 weeks of unsuccessful non-invasive treatment (physiotherapy, chiropractic treatment, rest, analgesia, or a combination)
In review [23] 		Adverse effects 1 to 3 months
with epidural corticosteroid injections (betamethasone 10–15 mg, 1 week apart up to 3 times until successful)
with discectomy (no further details reported)
Absolute results reported graphically
The RCT found that 2/50 (4%) people in the epidural group had an incidental dural puncture, and 3/50 (6%) people had recurrent disc herniation for 2 to 3 years' follow-up period 		Effect size not calculated discectomy
Open in a new tab

Further information on studies

The RCT also reported that corticosteroid injections significantly improved subjective limb pain, straight leg raising, lumbar flexion, and patient satisfaction in the short term at 2 weeks, but not after 2 weeks (data not reported).

The additional RCT also reported a significant improvement in straight leg raise at both 4 weeks and 12 months.

This systematic review reports on a double-blinded RCT with 228 participants in which the treatment group received an epidural injection of triamcinolone 80 mg plus 10 mL bupivacaine 0.25% and the placebo group received an epidural injection of normal saline. The RCT found that by 6 weeks the benefits of epidural corticosteroids were lost, and at 52 weeks, improvement in symptoms was 33% in the treatment group and 30% in the placebo group, an improvement that the authors of the systematic review conclude was probably related to the natural course of the disease.

The RCT allowed the 27 people in whom the epidural had failed to improve their symptoms (self-assessment) to receive discectomy. This group was analysed as failures for the epidural corticosteroid injections, and also as a separate subgroup. Two further people in each group who completely crossed over to receive other treatment were analysed according to the intervention they received. There seemed to be multiple hypothesis tests without mention of adjusting the analysis to account for this. Also, no attempt was made to blind the measurement of outcomes. These results should therefore be interpreted with caution.

Comment

None.

Substantive changes

Corticosteroids (epidural injections) New evidence added.[17] [18] [19] [21] Categorisation unchanged (Unknown effectiveness), as there remains insufficient evidence to judge the effects of this intervention because the evidence is inconsistent.

BMJ Clin Evid. 2011 Jun 28;2011:1118.

Cytokine inhibitors

Summary

Cytokine inhibitors do not seem to improve symptoms of sciatica caused by disc herniation.

A drug safety alert has been issued by the FDA on the risk of clinically significant liver injury associated with natalizumab.

Benefits and harms

Infliximab versus placebo:

We found one RCT comparing a cytokine inhibitor (infliximab) versus placebo (saline infusion over 2 hours).[25]

Pain

Compared with placebo Infliximab seems no more effective at 12 weeks or 12 months at improving leg or back pain scores in people with sciatic pain caused by herniated disc (moderate-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Pain
[25]
RCT		 41 people with acute or subacute (2–12 weeks' duration) sciatic pain, caused by herniated disc confirmed by MRI Median reduction in leg pain score (rated on a 100-mm visual analogue scale [VAS], details not reported) 12 weeks
43 mm with infliximab (single iv infusion of 5 mg/kg over 2 hours)
50 mm with placebo (saline infusion over 2 hours)
Mean difference –7 mm
95% CI −21 mm to +31 mm
P = 0.77 		Not significant
[25]
RCT		 41 people with acute or subacute (2–12 weeks' duration) sciatic pain, caused by herniated disc confirmed by MRI Median reduction in leg pain score (rated on a 100-mm VAS, details not reported) 1 year
38 mm with infliximab (single iv infusion of 5 mg/kg over 2 hours)
44 mm with placebo (saline infusion over 2 hours)
Mean difference –6 mm
95% CI −30 mm to +32 mm
P = 0.98 		Not significant
[25]
RCT		 41 people with acute or subacute (2–12 weeks' duration) sciatic pain, caused by herniated disc confirmed by MRI Median reduction in back pain score (rated on a 100-mm VAS, details not reported) 12 weeks
12 mm with infliximab (single iv infusion of 5 mg/kg over 2 hours)
4 mm with placebo (saline infusion over 2 hours)
Mean difference +8 mm
95% CI –19 mm to +16 mm
P = 0.93 		Not significant
[25]
RCT		 41 people with acute or subacute (2–12 weeks' duration) sciatic pain, caused by herniated disc confirmed by MRI Median reduction in back pain score (rated on a 100-mm VAS, details not reported) 12 months
13 mm with infliximab (single iv infusion of 5 mg/kg over 2 hours)
17 mm with placebo (saline infusion over 2 hours)
Mean difference –4 mm
95% CI −38 mm to +18 mm
P = 0.48 		Not significant
Open in a new tab

Functional improvement

Compared with placebo Infliximab may be no more effective at 12 weeks or 12 months at reducing disability index scores in people with sciatic pain caused by herniated disc (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Functional improvement
[25]
RCT		 41 people with acute or subacute (2–12 weeks' duration) sciatic pain, caused by herniated disc confirmed by MRI Oswestry Disability Index scores 12 weeks
with infliximab (single iv infusion of 5 mg/kg over 2 hours)
with placebo (saline infusion over 2 hours)
Absolute results reported graphically
P = 0.37 		Not significant
[25]
RCT		 41 people with acute or subacute (2–12 weeks' duration) sciatic pain, caused by herniated disc confirmed by MRI Oswestry Disability Index scores 1 year
28 with infliximab (single iv infusion of 5 mg/kg over 2 hours)
23 with placebo (saline infusion over 2 hours)
P = 0.48 		Not significant
[25]
RCT		 41 people with acute or subacute (2–12 weeks' duration) sciatic pain, caused by herniated disc confirmed by MRI Median cumulative sick leave 12 weeks
28 days with infliximab (single iv infusion of 5 mg/kg over 2 hours)
25 days with placebo (saline infusion over 2 hours)
P = 0.91 		Not significant
[25]
RCT		 41 people with acute or subacute (2–12 weeks' duration) sciatic pain, caused by herniated disc confirmed by MRI Median cumulative sick leave 1 year
42 days with infliximab (single iv infusion of 5 mg/kg over 2 hours)
25 days with placebo (saline infusion over 2 hours)
P = 0.60 		Not significant
Open in a new tab

Need for surgery

Compared with placebo Infliximab seems no more effective at 12 weeks or 12 months at reducing the requirement for surgery in people with sciatic pain caused by herniated disc (moderate-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Need for surgery
[25]
RCT		 41 people with acute or subacute (2–12 weeks' duration) sciatic pain, caused by herniated disc confirmed by MRI Proportion of people having discectomy 12 weeks
7/21 (33%) with infliximab (single iv infusion of 5 mg/kg over 2 hours)
7/19 (37%) with placebo (saline infusion over 2 hours)
P = 0.60 		Not significant
[25]
RCT		 41 people with acute or subacute (2–12 weeks' duration) sciatic pain, caused by herniated disc confirmed by MRI Proportion of people having discectomy 1 year
8/21 (38%) with infliximab (single iv infusion of 5 mg/kg over 2 hours)
8/19 (42%) with placebo (saline infusion over 2 hours)
P = 1.0 		Not significant
Open in a new tab

Adverse effects

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Adverse effects
[25]
RCT		 41 people with acute or subacute (2–12 weeks' duration) sciatic pain, caused by herniated disc confirmed by MRI Adverse effects 12 weeks
3/21 (14%) with infliximab (single iv infusion of 5 mg/kg over 2 hours)
0/19 (0%) with placebo (saline infusion over 2 hours)
P = 0.23 		Not significant
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Other cytokine inhibitors (adalimumab, etanercept, or natalizumab):

A drug safety alert has been issued by the FDA on the risk of clinically significant liver injury associated with natalizumab (www.fda.gov).

Further information on studies

None.

Drug safety alert

FDA issues drug safety alert on the increased risk of lymphoma and other malignancies in children and adolescents, and the risks of leukaemia and new-onset psoriasis, associated with TNF blockers (04 August 2009).

A drug safety alert has been issued on the increased risk of lymphoma and other malignancies in children and adolescents, and the risks of leukaemia and new-onset psoriasis, associated with TNF blockers (http://www.fda.gov).

Comment

One RCT comparing adalimumab versus placebo in people with acute and severe radicular leg pain and imaging-confirmed lumbar disc herniation has been published subsequent to the search date of this Clinical Evidence review.[26] We will assess this RCT for inclusion at the next update of this review.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jun 28;2011:1118.

Muscle relaxants

Summary

We found no direct information from RCTs about muscle relaxants in the treatment of people with symptomatic herniated lumbar disc.

Benefits and harms

Muscle relaxants:

We found no systematic review or RCTs on the use of muscle relaxants for treatment of people with symptomatic herniated lumbar disc.

Further information on studies

None.

Comment

None.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jun 28;2011:1118.

NSAIDs

Summary

NSAIDs do not seem to improve symptoms of sciatica caused by disc herniation.

A drug safety alert has been issued by the European Medicines Agency (EMEA) on the increased risk of GI adverse effects and serious skin reactions associated with piroxicam.

Benefits and harms

NSAIDs versus placebo:

We found one systematic review (search date 1998, 3 RCTs, 321 people).[15]

Pain

Compared with placebo NSAIDs may be no more effective at improving global pain at 5 to 30 days in people with sciatic pain caused by disc herniation (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Pain
[15]
Systematic review		 321 people
3 RCTs in this analysis		 Proportion of people with improved pain 5 to 30 days
80/172 (47%) with NSAIDs
57/149 (38%) with placebo
OR for global improvement 0.99
95% CI 0.60 to 1.70 		Not significant
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Adverse effects

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Adverse effects
[15]
Systematic review		 321 people
3 RCTs in this analysis		 Adverse effects
with NSAIDs
with placebo
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NSAIDs versus electroacupuncture:

We found one small RCT (40 people with sciatica for >2 years caused by disc herniation; verified by MRI, CT scan, or x-ray; see comment below) comparing an NSAID (diclofenac 50 mg 3 times/day) versus electroacupuncture (electrical stimulator [G6805-II] for 25 minutes/day for 7 days).[27]

Pain

Compared with electroacupuncture We don't know how NSAIDs compare with electroacupuncture at improving pain (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Pain after treatment
[27]
RCT		 40 people with sciatica for >2 years caused by disc herniation; verified by MRI, CT, or x-ray Mean angle of Lasègue's sign during straight leg raising test end of treatment
70.8° with diclofenac 50 mg three times daily
76.7° with electroacupuncture (electrical stimulator [G6805-II] for 25 minutes/day for 7 days)
Mean difference 5.8°
95% CI 4.6° to 7.0°
P <0.05 		Effect size not calculated electroacupuncture
[27]
RCT		 40 people with sciatica for >2 years caused by disc herniation; verified by MRI, CT, or x-ray Buttock tenderness visual analogue scale (VAS) (0 = no tenderness to 10 = extreme tenderness, converted to a scale of 0–100) end of treatment
33.3 with diclofenac 50 mg three times daily
25.7 with electroacupuncture (electrical stimulator [G6805-II] for 25 minutes/day for 7 days)
Mean difference –7.6
95% CI –9.3 to –6.0
P <0.05 		Effect size not calculated electroacupuncture
[27]
RCT		 40 people with sciatica for >2 years caused by disc herniation; verified by MRI, CT, or x-ray Leg tenderness VAS (0 = no tenderness to 10 = extreme tenderness, converted to a scale of 0–100) end of treatment
25.3 with diclofenac 50 mg three times daily
21.0 with electroacupuncture (electrical stimulator [G6805-II] for 25 minutes/day for 7 days)
P >0.05 		Not significant
[27]
RCT		 40 people with sciatica for >2 years caused by disc herniation; verified by MRI, CT, or x-ray Tenderness in posterior side of the thigh VAS (0 = no tenderness to 10 = extreme tenderness, converted to a scale of 0–100) at end of treatment
28.6 with diclofenac 50 mg three times daily
21.2 with electroacupuncture (electrical stimulator [G6805-II] for 25 minutes/day for 7 days)
P >0.05 		Not significant
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Functional improvement

Compared with electroacupuncture NSAIDs may be less effective at improving straight leg raising in people with sciatica caused by disc herniation (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Functional improvement
[27]
RCT		 40 people with sciatica for >2 years caused by disc herniation; verified by MRI, CT, or x-ray Mean angle of Lasègue's sign during straight leg raising test at end of treatment
70.8° with diclofenac 50 mg three times daily
76.7° with electroacupuncture (electrical stimulator [G6805-II] for 25 minutes/day for 7 days)
Mean difference 5.8°
95% CI 4.6° to 7.0°
P <0.05 		Effect size not calculated electroacupuncture
Open in a new tab

Adverse effects

No data from the following reference on this outcome.[27]

Further information on studies

The absolute data in the RCTs relate to the outcomes of improvement in pain (3 RCTs) and return to work (1 RCT). However, the meta-analysis used the outcome measure of global improvement. The relationship between these measures is unclear.

The RCT comparing diclofenac versus electroacupuncture may have included people without a conclusive diagnosis of disc herniation, as x-ray was used for diagnosis in some cases. The outcome measures used in this RCT, such as buttock tenderness, may not be comparable to more commonly reported pain measures. The method of randomisation was not reported.

Comment

Adverse effects of NSAIDs:

NSAIDs may cause GI, cardiovascular, and other complications (see review on NSAIDs). COX-2 inhibitors have been particularly associated with an increased risk of cardiovascular events, leading to the withdrawal of rofecoxib in September 2004.[28] [29] A drug safety alert has been issued by the European Medicines Agency (EMEA) on the increased risk of GI adverse effects and serious skin reactions associated with piroxicam (www.emea.europa.eu).

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jun 28;2011:1118.

Spinal manipulation

Summary

With regard to non-drug treatments, spinal manipulation seems more effective at relieving local or radiating pain in people with acute back pain and sciatica with disc protrusion compared with sham manipulation, although concerns exist regarding possible further herniation from spinal manipulation in people who are surgical candidates.

Benefits and harms

Spinal manipulation versus placebo or sham treatment:

We found one systematic review (search date 2006)[30] and one subsequent RCT.[31] The review identified no RCTs comparing spinal manipulation versus placebo. The subsequent RCT compared active spinal manipulation (assessment of range of motion, soft tissue manipulations, and brisk rotational thrusting) versus sham manipulation (soft muscle pressing and no rapid thrusts).[31] We also found three subsequent systematic reviews evaluating adverse effects.[32] [33] [34]

Pain

Compared with sham manipulation Active spinal manipulation is more effective at 6 months at relieving local or radiating pain in people with acute back pain and sciatica with disc protrusion (moderate-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Pain
[31]
RCT		 102 people with acute back pain (pain <10 days and pain-free for the previous 3 months) and sciatica with disc protrusion Proportion of people who were free of local or radiating pain (visual analogue scale [VAS] score = 0 on scale where 0 = no pain to 10 = unbearable pain) 6 months
15/53 (28%) with active manipulation
3/49 (6%) with sham manipulation
P <0.005 		Effect size not calculated active manipulation
[31]
RCT		 102 people with acute back pain (pain <10 days and pain-free for the previous 3 months) and sciatica with disc protrusion Proportion of people who were free of radiating pain (VAS score = 0 on scale where 0 = no pain to 10 = unbearable pain) 6 months
29/53 (55%) with active manipulation
10/49 (20%) with sham manipulation
P <0.0001 		Effect size not calculated active manipulation
[31]
RCT		 102 people with acute back pain (pain <10 days and pain-free for the previous 3 months) and sciatica with disc protrusion Treatment failure (defined as stopping of treatment because of no pain reduction) 6 months
1/53 (1.9%) with active manipulation
1/49 (2.0%) with sham manipulation
P value and significance not reported
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Functional improvement

Compared with sham manipulation We don't know whether microdiscectomy is more effective at improving physical function (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Functional improvement
[31]
RCT		 102 people with acute back pain (pain <10 days and pain-free for the previous 3 months) and sciatica with disc protrusion Mean score for Short Form (SF)-36 Health Survey, physical functioning domain 6 months
67.4 with active manipulation
60.5 with sham manipulation
P value not reported
Reported as not significant 		Not significant
Open in a new tab

Adverse effects

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Adverse effects
[30]
Systematic review		 People with herniated lumbar disc (number not reported) Worsening of neurological symptoms
with people receiving spinal manipulation
with baseline
Absolute results not reported
[32]
Systematic review		 135 cases of serious complications after spinal manipulation; published between 1950 and 1980 Serious complications
with people receiving spinal manipulation
with baseline
Absolute results not reported
[33]
Systematic review		 4712 treatments in 1058 people having both cervical and lumbar spinal manipulations Adverse effects
with people receiving spinal manipulation
with baseline
Absolute results not reported
[34]
Systematic review		 People with herniated disc (number not reported) Further disc herniation or cauda equina syndrome
with people receiving spinal manipulation
with baseline
Absolute results not reported
Open in a new tab

No data from the following reference on this outcome.[31]

Spinal manipulation versus heat treatment:

We found one systematic review (search date 2006, 1 RCT).[30]

Patient perception of improvement

Compared with heat treatment Spinal manipulation may be more effective than three sessions of infrared heat treatment a week at increasing overall self-perceived improvement at 2 weeks in people with herniated lumbar disc (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Patient perception of improvement
[30]
RCT		 233 people, 132 people randomised to manipulation and 101 people randomised to heat
Data from 1 RCT		 Self-perceived improvement 2 weeks
98/123 (80%) with spinal manipulation (by a physiotherapist, every day if necessary; total number of sessions not reported)
56/84 (67%) with infrared heat (3 times weekly)
P value not reported
Reported as significant
The RCT provided weak evidence that manipulation may be effective in the short term because of methodological limitations (see further information on studies below) 		Effect size not calculated spinal manipulation
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Adverse effects

No data from the following reference on this outcome.[30]

Spinal manipulation versus exercise therapy:

We identified one systematic review (search date 2006, see comment below) that identified one methodologically weak RCT.[30]

Pain

Compared with exercise therapy We don't know whether spinal manipulation is more effective at 1 month or at 3 to 4 months at improving pain scores in people with herniated lumbar disc (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Pain
[30]
Systematic review
4-armed trial 		322 people
Data from 1 RCT		 Pain scores 28 days and at 3 to 4 months
with spinal manipulation
with exercise therapy
with manual traction
with corsets
Absolute results not reported
Reported no significant difference among groups (interventions compared using a factorial design)
P value not reported
The RCT had weak methods; see further information on studies 		Not significant
Open in a new tab

Patient perception of improvement

Compared with exercise therapy We don't know whether spinal manipulation is more effective at 1 month or at 3 to 4 months at increasing overall self-perceived improvement in people with herniated lumbar disc (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Patient perception of improvement
[30]
Systematic review
4-armed trial 		322 people
Data from 1 RCT		 Self-perceived improvement 28 days and at 3 to 4 months
with spinal manipulation
with exercise therapy
with manual traction
with corsets
Absolute results not reported
Reported no significant difference among groups (interventions compared using a factorial design)
P value not reported
The RCT had weak methods; see further information on studies 		Not significant
Open in a new tab

Adverse effects

No data from the following reference on this outcome.[30]

Spinal manipulation versus traction:

We identified one systematic review (search date 2006, 2 RCTs).[30]

Patient perception of improvement

Compared with traction We don't know whether spinal manipulation is more effective at 1 month at increasing overall self-perceived improvement in people with herniated lumbar disc (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Patient perception of improvement
[30]
Systematic review
4-armed trial 		322 people
Data from 1 RCT		 Self-perceived improvement 28 days
with spinal manipulation
with manual traction
Absolute results not reported
Reported no significant difference between spinal manipulation and manual traction (interventions compared using a factorial design)
P value not reported
The RCT had weak methods; see further information on studies 		Not significant
Open in a new tab

Functional improvement

Compared with traction Spinal manipulation may be more effective at improving lumbar function and straight leg raising in people with herniated lumbar disc (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Functional improvement
[35]
RCT		 112 people with symptomatic herniated lumbar disc
In review [30] 		Proportion of people "improved" or "cured" timescale not reported
54/62 (87%) with pulling and turning manipulation
33/50 (66%) with traction
P <0.05 		Effect size not calculated spinal manipulation
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Adverse effects

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Adverse effects
[35]
RCT		 112 people with symptomatic herniated lumbar disc
In review [30] 		Syncope timescale not reported
with pulling and turning manipulation
with traction
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Further information on studies

Spinal manipulation versus placebo or sham treatment: Both groups were treated according to a pre-planned 30-day protocol of up to 20 sessions lasting 5 minutes on 5 days a week by experienced chiropractors with the same formal training. Pain scores were assessed using a 10-cm visual analogue scale (VAS; 0 = no pain to 10 = unbearable pain). The review identified one systematic review of adverse effects, and a small retrospective medical record review of 18 people reporting significant worsening of neurological symptoms immediately after spinal manipulation by different chiropractors in New York State. Although people were not scanned before treatment, 12 people had disc herniation (8 of whom had lumbar disc herniation) when scanned by MRI or CT after the adverse event occurred. Two people had symptoms at the site of the manipulation who had originally presented symptoms elsewhere. The author of the review suggested that imaging should be carried out before manipulation to avoid worsening any existing significant disc herniation. However, this was a small medical record review, and does not state how many people in total received spinal manipulation.

The largest study identified by the review (4712 treatments in 1058 people having both cervical and lumbar spinal manipulations) found that the most common reaction was local discomfort (53%), followed by headache (12%), tiredness (11%), radiating discomfort (10%), dizziness (5%), nausea (4%), hot skin (2%), and other complaints (2%). The incidence of serious adverse effects is reported as rare, and is estimated from published case series and reports to occur in one in 1–2 million treatments. The most common serious effects were cerebrovascular accidents (total proportion of people having manipulations not reported, rate of adverse effects cannot be estimated). However, it is difficult to assess whether such events are directly related to treatment. The percentages included both cervical and lumbar spinal manipulations, which may overestimate the effect of lumbar spinal manipulations. The authors of the review advise caution in interpreting these results, as they are speculative and based on assumptions about the number of manipulations performed and of unreported cases.

The estimates calculated were based on rough estimates in the literature (best available) using what the author thought to be the most accurate, recent, or conservative values. This estimate is also prone to error because of the possible lack of reporting of many cases of disc herniation or cauda equina syndrome. Mild symptoms after spinal manipulation are not included in these calculations. More reliable data are needed on the incidence of specific risks of spinal manipulation. It is unclear whether the populations studied in the RCTs cited included people who were surgical candidates for disc herniation. Concerns exist regarding possible further herniation from spinal manipulation in people who are surgical candidates.

Spinal manipulation versus heat treatment: The review commented that the identified RCT provided weak evidence, because it did not report method of randomisation, group baseline characteristics, whether the control group received the same number of treatments as the other group, what happened to those lost to follow-up at 2 weeks (9/132 [7%] with spinal manipulation v 22/123 [18%] with heat), or whether it used intention-to-treat analysis.

Spinal manipulation versus exercise therapy or traction: The review commented on the methodological weaknesses of the 4-armed RCT, which did not describe the method of randomisation, and was not single-blinded. It gave insufficient detail about baseline characteristics for groups at baseline, and may have included people without herniated disc.

Comment

We found one further trial on manipulative reduction that was written in Chinese.[37] We are currently awaiting full text translation and we will assess this for inclusion in our next update.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jun 28;2011:1118.

Acupuncture

Summary

We found insufficient evidence about acupuncture to judge its efficacy in treating people with herniated disc.

Benefits and harms

Acupuncture versus sham acupuncture:

We found one systematic review (search date 1998)[38] in people with back and neck pain, which identified one small RCT of acupuncture in people with sciatica.

Pain

Compared with sham acupuncture We don't know whether acupuncture is more effective at reducing pain intensity at rest in people with acute sciatica caused by disc herniation (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Pain
[38]
Systematic review		 30 people with acute sciatica
Data from 1 RCT		 Pain intensity at rest 5 days
with acupuncture at electronically detected non-traditional points
with sham acupuncture
The RCT found that acupuncture significantly improved three outcomes compared with sham acupuncture, and that there was an overall benefit of acupuncture. However, the review disagreed with the overall beneficial conclusion of the RCT, only finding a significant difference between groups in 3/12 (25%) outcome measures, and no significant difference between acupuncture and sham acupuncture in pain intensity at rest — the most clinically relevant outcome — after 5 days (absolute numbers and P value not reported) 		Not significant
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Adverse effects

No data from the following reference on this outcome.[38]

Laser acupuncture versus sham laser acupuncture:

We found one systematic review (search date 1998)[38] in people with back and neck pain, which identified one small crossover RCT of laser acupuncture at traditional points versus sham laser acupuncture.

Pain

Compared with sham laser acupuncture We don't know whether laser acupuncture is more effective at reducing pain intensity in people with radicular and pseudo-radicular cervical and lumbar pain caused by stenosis, herniated disc, or both (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Pain
[38]
Systematic review
Crossover design 		42 people, radicular and pseudo-radicular cervical and lumbar pain caused by stenosis, herniated disc, or both
Data from 1 RCT		 Reduction of pain intensity after 24 hours
with laser acupuncture at traditional points
with sham laser acupuncture
The review found no significant difference between groups in reduction of pain intensity after 24 hours, although pain was significantly improved in the laser acupuncture group at 15 minutes, 1 hour, and 6 hours compared with sham laser acupuncture 		Not significant
Open in a new tab

Adverse effects

No data from the following reference on this outcome.[38]

Electroacupuncture versus NSAIDs:

See option on NSAIDs.

Adding acupuncture to manipulation compared with manipulation alone:

We found one RCT comparing acupuncture plus manipulation versus manipulation alone.[39]

Pain

Adding acupuncture to manipulation compared with manipulation alone Adding acupuncture to manipulation may be more effective at improving pain in people with herniated lumbar disc (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Pain
[39]
RCT		 58 people with diagnosed herniated lumbar disc confirmed by imaging (details not reported); duration of illness 24 days to 10 years Change in pain from baseline (visual analogue scale: 0 = no pain, 10 = unbearable severe pain) evaluated after 20 sessions (time not reported)
from 4.98 to 0.83 with acupuncture plus manipulation
from 4.77 to 2.85 with manipulation alone
P <0.01 		Effect size not calculated acupuncture plus manipulation
[39]
RCT		 58 people with diagnosed herniated lumbar disc confirmed by imaging (details not reported); duration of illness 24 days to 10 years Recovery rate (the proportion of people with 100% improvement according to the Japanese Orthopaedic Association Lumbar Vertebral Disease Therapy Scale) evaluated after 20 sessions (time not reported)
7/30 (23%) with acupuncture plus manipulation
3/28 (11%) with manipulation alone
P <0.05 		Effect size not calculated acupuncture plus manipulation
[39]
RCT		 58 people with diagnosed herniated lumbar disc confirmed by imaging (details not reported); duration of illness 24 days to 10 years Overall effectiveness (the proportion of people with improvements of >25% according to the Japanese Orthopaedic Association Lumbar Vertebral Disease Therapy Scale) evaluated after 20 sessions (time not reported)
7/30 (23%) with acupuncture plus manipulation
3/28 (11%) with manipulation alone
P <0.05 		Effect size not calculated acupuncture plus manipulation
Open in a new tab

Adverse effects

No data from the following reference on this outcome.[39]

Further information on studies

Acupoints and technique of acupuncture were selected depending on the location of pain, level of pain, and duration of symptoms, and involved 30 minutes' treatment daily for 2 courses of 10 sessions, with 3 to 5 days' gap between courses. Manipulation involved 20 minutes each session of forcible thrusting, pinching, grasping, rolling, and pulling of the lower back and legs, pressing acupoints, relaxing muscles, followed by passive exercises of low back and legs and oblique pulling of the low back.

Comment

None.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jun 28;2011:1118.

Advice to stay active

Summary

We found no direct information from RCTs about advice to stay active in the treatment of people with sciatica caused by lumbar disc herniation.

Benefits and harms

Advice to stay active:

We found one systematic review (search date 1998) of conservative treatments for sciatica caused by disc herniation, which found no RCTs of advice to stay active.[15] We found no subsequent RCTs.

Further information on studies

None.

Comment

None.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jun 28;2011:1118.

Exercise therapy

Summary

We found insufficient evidence about exercise to judge its efficacy in treating people with herniated disc.

Benefits and harms

Exercise therapy versus placebo or no treatment:

We found one systematic review (search date 1998) of conservative treatments for sciatica caused by disc herniation.[15] It found no RCTs comparing exercise therapy versus no treatment or placebo. We found no subsequent RCTs.

Exercise therapy versus spinal manipulation:

See option on spinal manipulation.

Exercise therapy versus traction:

We found two systematic reviews (search dates 1998[40] and 2006[30]), each of which identified a different RCT.

Pain

Compared with traction We don't know whether exercise therapy is more effective than isometric exercises at achieving global improvement in pain at 1 month in people with herniated lumbar disc (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Global improvement scores
[40]
Systematic review		 50 people admitted for possible surgery for herniated lumbar disc, verified by myelogram
Data from 1 RCT		 Pain free or improved
10/26 (38%) with isometric exercise
10/24 (42%) with manual traction
Reported as not significant 		Not significant
[30]
Systematic review
4-armed trial 		322 people
Data from 1 RCT		 Overall self-perceived improvement, pain scores or return to work after 28 days and at 3 to 4 months
with exercise therapy
with manual traction
with spinal manipulation
with corsets
Absolute results not reported
Reported as not significant
P value not reported 		Not significant
Open in a new tab

Adding exercise plus education to conventional non-surgical treatment versus conventional non-surgical treatment alone:

We found one RCT (40 people with invertebral disc herniation) comparing exercise plus education plus conventional non-surgical treatment versus conventional non-surgical treatment alone.[41]

Functional improvement

Adding exercise plus education to conventional non-surgical treatment compared with conventional non-surgical treatment alone We don't know whether adding exercise and education to conventional non-surgical treatment is more effective at 6 months to 3 years at improving lumbodorsal function or decreasing recurrences in people with invertebral disc herniation (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Functional improvement
[41]
RCT		 40 people with invertebral disc herniation Proportion of people in both groups with improvement in lumbodorsal function 6 months
with exercise plus education plus conventional non-surgical treatment
with conventional non-surgical treatment alone
P <0.01
Weak methods; see further information on studies 		Effect size not calculated exercise plus education
[41]
RCT		 40 people with invertebral disc herniation People with "excellent" or "good" efficacy (assessed using the modified Macnab criteria) 3 years
17/20 (85%) with exercise plus education plus conventional non-surgical treatment
11/20 (55%) with conventional non-surgical treatment alone
P <0.01
Weak methods; see further information on studies 		Effect size not calculated exercise plus education
[41]
RCT		 40 people with invertebral disc herniation Recurrence 3 years
4/20 (20%) with exercise plus education plus conventional non-surgical treatment
11/20 (55%) with conventional non-surgical treatment alone
P <0.01
Weak methods; see further information on studies 		Effect size not calculated exercise plus education
Open in a new tab

Adverse effects

No data from the following reference on this outcome.[41]

Further information on studies

Isometric exercises were done for 20 minutes daily for 5 to 7 days; abdominal, back, hip, and thigh muscle contractions held for 6 to 8 seconds, repeated 5 to 10 times for each muscle group in crook and side-lying, and supine positions. Manual traction involved 10 minutes of static traction daily for 5 to 7 days at a force of 300 N. The global measure of improvement used in the RCT comparing exercise versus traction was assessed by a neurologist (blind to intervention received), based on a 4-point scale that ranged from "symptom free" to "unchanged". An improvement was considered as: 15 cm or greater increase in straight leg raising test; 2 cm or greater increase in range of movement of lumbar spine in sagittal plane; 25% or greater reduction in pain measured by pain intensity (visual analogue score 0–10 cm) and pain distribution (pain drawing); or an improvement in activities of daily living (interview graded according to Roland Morris Disability Questionnaire). Only short-term outcomes were measured — long-term effectiveness was not evaluated.

The review commented on the methodological weaknesses of the 4-arm RCT, which did not describe the method of randomisation, and was not single blinded. It gave insufficient detail about baseline characteristics for groups at baseline, and may have included people without herniated disc.

The authors of the RCT reported a significant difference between the groups in self-assessed function at 6 months, but when these differences were recalculated by the contributor for this Clinical Evidence review, they were not significant. Exercise involved dorsal muscle strengthening with self-massage of the lumbar region and hands (frequency not reported). Education involved rehabilitation education (knowledge and understanding about the condition, psychological rehabilitation (dispelling adverse moods, adjusting patient's psychology, and strengthening their resolve and confidence in recovery), and education on preventive methods (advice on posture and activities). Conventional non-surgical treatment was not defined.

Comment

None.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jun 28;2011:1118.

Heat

Summary

We found insufficient RCT evidence about heat to judge its efficacy in treating people with herniated disc.

Benefits and harms

Heat versus placebo or no treatment:

We found one systematic review (search date 1998) of conservative treatments for sciatica caused by disc herniation, which identified no RCTs on the use of heat for herniated lumbar disc.[15] We found no subsequent RCTs.

Heat versus spinal manipulation:

See option on spinal manipulation.

Further information on studies

None.

Comment

None.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jun 28;2011:1118.

Ice

Summary

We found no direct information from RCTs about ice in the treatment of people with sciatica caused by lumbar disc herniation.

Benefits and harms

Ice compared with no ice:

We found one systematic review (search date 1998) of conservative treatments for sciatica caused by disc herniation, which identified no RCTs on the use of ice for herniated lumbar disc.[15] We found no subsequent RCTs.

Further information on studies

None.

Comment

None.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jun 28;2011:1118.

Massage

Summary

We found insufficient information from RCTs to assess the effects of massage in people with herniated lumbar disc.

Benefits and harms

Massage versus no massage:

We found one systematic review (search date 1998) of conservative treatments for sciatica caused by disc herniation, which found no RCTs of massage.[15]

Massage/manipulation versus massage/manipulation plus functional training exercises versus traction:

We found one RCT that was a three-arm trial comparing massage/manipulation versus massage/manipulation plus functional training exercises versus traction.[42]

Pain

Massage/manipulation compared with massage/manipulation plus functional training exercises We don't know whether massage/manipulation is more effective at improving lumbar pain in people with herniated lumbar disc (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Pain
[42]
RCT
3-armed trial 		110 people "Significant efficacy" (defined as cure or >60% improvement from baseline in lumbar pain and function)
39/55 (71%) with massage/manipulation
39/55 (71%) with massage/manipulation plus functional training exercises
Reported as not significant for massage/manipulation v massage/manipulation plus functional training exercises 		Not significant
Open in a new tab

Adverse effects

No data from the following reference on this outcome.[42]

Massage/manipulation versus traction:

We found one RCT that was a three-arm trial comparing massage/manipulation versus massage/manipulation plus functional training exercises versus traction.[42]

Pain

Massage/manipulation compared with traction Massage/manipulation may be more effective at improving outcomes in people with herniated lumbar disc (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Pain
[42]
RCT
3-armed trial 		110 people "Significant efficacy" (defined as cure or >60% improvement from baseline in lumbar pain and function)
39/55 (71%) with massage/manipulation
24/55 (44%) with traction
P >0.05 for massage/manipulation v traction 		Not significant
Open in a new tab

Adverse effects

No data from the following reference on this outcome.[42]

Further information on studies

Massage/manipulation involved 20-minute sessions, three times weekly, for a total of 20 sessions of waist-rolling massage and passive backward stretching, lumbar manual vertebral mobilisation, rotational manipulation, passive hip extension while lying prone, pressure correction, improved lumbar vertebrae inclined turning, prone lying and active backward stretching, forced leg raising, and remedial manipulation. Massage/manipulation plus functional training was as above, plus exercises of the lumbar and abdominal muscles, including stretching and strengthening exercises for the back and legs, for 20 to 30 minutes, three times weekly before going to sleep. People receiving traction had 20 minutes daily for a total of 20 treatments using a TF-4 computerised traction bed, starting at half of body weight and increasing to full body weight.

Comment

Although the intervention used in the RCT was called massage, it included spinal manipulation techniques.[42] Therefore, the results may not be comparable with other massage-only interventions.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jun 28;2011:1118.

Bed rest

Summary

Bed rest does not seem effective in treating people with sciatica caused by disc herniation.

Benefits and harms

Bed rest versus no treatment (watchful waiting):

We found one systematic review[15] and one subsequent RCT.[43] The systematic review (search date 1998) identified no RCTs of bed rest for treatment of people with symptomatic herniated disc.[15]

Pain

Compared with no treatment Bed rest may be no more effective than watchful waiting at improving pain scores at 12 weeks in people with sciatica (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Pain
[43]
RCT		 183 people with sciatica, intensity sufficient to justify 2 weeks of bed rest as treatment Mean pain scores (McGill Pain Questionnaire) 12 weeks
8 with bed rest at home (instructed to stay in the supine or lateral recumbent position with 1 pillow under the head)
7 with watchful waiting
Difference –0.6
95% CI –3.3 to +2.1
Based on regression analysis 		Not significant
Open in a new tab

Functional improvement

Compared with no treatment Bed rest may be no more effective than watchful waiting at improving disability scores at 12 weeks in people with sciatica (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Functional improvement
[43]
RCT		 183 people with sciatica, intensity sufficient to justify 2 weeks of bed rest as treatment Revised Roland Morris Disability Questionnaire 12 weeks
15.2 with bed rest at home (instructed to stay in the supine or lateral recumbent position with 1 pillow under the head)
15.7 with watchful waiting
Difference –0.5
95% CI –2.6 to +1.6 		Not significant
Open in a new tab

Patient perception of improvement

Compared with no treatment Bed rest may be no more effective than watchful waiting at improving people's perception of improvement at 12 weeks in people with sciatica (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Patient perception of improvement
[43]
RCT		 183 people with sciatica, intensity sufficient to justify 2 weeks of bed rest as treatment Mean satisfaction scores 12 weeks
7 with bed rest at home (instructed to stay in the supine or lateral recumbent position with 1 pillow under the head)
8 with watchful waiting
Difference –0.1
95% CI –0.6 to +0.3
Based on regression analysis 		Not significant
Open in a new tab

Adverse effects

No data from the following reference on this outcome.[15] [43]

Further information on studies

The regression analysis in the RCT adjusted odds ratios and differences between treatments for several variables including baseline differences in age, sex, presence or absence of paresis, disease duration, and people's history with respect to sciatica.

Comment

We found one further systematic review (search date 1996) of bed rest and advice to stay active in people with acute low back pain, which found three RCTs including people with sciatica or radiating pain.[44] However, no further details were given on the proportion of people in these RCTs with herniated disc. The review concluded that there was little evidence on bed rest specifically for herniated lumbar disc, although the RCTs identified questioned the efficacy of bed rest for sciatica.[44]

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jun 28;2011:1118.

Traction

Summary

Traction does not seem effective in treating people with sciatica caused by disc herniation.

Benefits and harms

Traction versus no traction or sham traction:

We found one systematic review (search date 1998)[15] and one subsequent RCT.[45]

Pain

Traction compared with no traction or sham traction Traction may be no more effective at achieving overall global improvement or pain intensity in people with sciatica caused by lumbar disc herniation (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Pain
[15]
Systematic review		 329 people with sciatica who may or may not have had disc herniation
4 RCTs in this analysis		 Global improvement
with traction
with no traction or sham traction
Absolute results not reported
OR 1.2
95% CI 0.7 to 2.0 		Not significant
Open in a new tab

No data from the following reference on this outcome.[45]

Functional improvement

Manual traction compared with no traction or sham traction We don't know whether manual traction is more effective at increasing Oswestry Disability Index scores in people with herniated disc (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Functional improvement
[45]
RCT		 102 people with herniated disc diagnosed by clinical examination or MRI Mean changes from baseline Oswestry Disability Index scores
19.25 with manual traction
25.25 with sham traction
Mean difference +6.00
95% CI –0.42 to +12.43
P = 0.067 		Not significant
Open in a new tab

No data from the following reference on this outcome.[15]

Patient perception of improvement

Manual traction compared with no traction or sham traction We don't know whether manual traction is more effective at increasing the number of people reporting complete recovery or much improvement in people with herniated disc (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Patient perception of improvement
[45] 102 people with herniated disc diagnosed by clinical examination or MRI Proportion of people reporting a complete recovery or much improvement
38/54 (70%) with manual traction
34/48 (71%) with sham traction
P = 0.889 		Not significant
Open in a new tab

Traction versus exercise therapy:

See exercise therapy.

Traction versus spinal manipulation:

See spinal manipulation.

Traction versus massage:

See massage.

Autotraction versus passive traction:

The review[15] identified two RCTs[46] [47] comparing autotraction versus passive traction.

Functional improvement

Autotraction compared with passive traction We don't know whether autotraction is more effective at achieving overall global improvement (based on Lasègue's sign, functional ability, and patient's opinion) or at increasing response rates immediately after treatment in people with herniated lumbar disc (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Functional improvement
[46]
RCT		 49 hospitalised people with confirmed herniated disc
In review [15] 		Global assessment by neurologist: AR for "no effect" 2 weeks
21/26 (81%) with autotraction
16/23 (70%) with manual traction
Results at 3 months were the same as for 2 weeks
P values and CIs not reported 		Not significant
[47]
RCT		 44 people with herniated disc verified by CT scan or MRI
In review [15] 		Proportion of people who classified themselves as responders immediately after treatment
17/22 (77%) with 3 sessions of autotraction
4/22 (18%) with 5 sessions of passive traction
P <0.001 		Effect size not calculated autotraction
Open in a new tab

Adverse effects

No data from the following reference on this outcome.[15] [46] [47]

Further information on studies

The RCTs identified by the review comparing traction versus placebo used a variety of traction techniques and placebo treatments (comparisons: continuous traction, about 45 kg for 30 minutes/day for up to 3 weeks v infrared heat three times/week; intermittent motorised traction force of a third of body weight for 20 minutes/day for 5–7 days v simulated traction of 7 kg; motorised traction force of 40–70 kg for 20 minutes/day for 5–7 days v simulated traction [force not reported]; autotraction with a force of a third to full body weight in sessions lasting 1 hour plus hyperextension orthosis v orthosis only). The review included RCTs in people with sciatica, who may not have had lumbar disc herniation. An earlier systematic review (search date 1992) identified all 4 placebo-controlled RCTs identified in the later review, but considered two of these RCTs in acute low back pain rather than herniated lumbar disc. Neither of the RCTs considered to be in people with lumbar disc herniation by both systematic reviews found any significant differences between traction and placebo.

The RCT compared manual traction (20 minutes, 3 times weekly: intermittent hold for 45 seconds, rest for 30 seconds, 90° hip flexion and 90° knee flexion, therapist applied force of 35–50% of body weight) versus sham traction (same as manual traction, but therapist applying <20% of body weight). People in both groups also received NSAIDs, an advice booklet on appropriate activities for back protection and back exercises, and application of superficial heat to the back at home.

The RCT compared autotraction (using the Lind technique; held from a few seconds up to a couple of minutes with force between a third to full body weight, session lasting 1 hour) versus manual traction (static traction held by therapist weight up to 30 kg twice, each pull lasting 5 minutes).

The RCT compared three sessions of autotraction (Natchev technique with specially designed traction table) versus 5 sessions of passive traction (static traction held by chain to table of 35% of body weight; sessions of 45 minutes every day for 5 days). In the RCT, people classified their condition as "responsive" (fully recovered or improved), "unchanged", or "worsened".

Comment

We also found a study on electroacupuncture under continuous traction, which was written in Chinese.[49] We are currently awaiting full text translation and we will assess this for inclusion in our next update.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jun 28;2011:1118.

Microdiscectomy

Summary

Microdiscectomy and standard discectomy seem to increase self-reported improvement to a similar extent.

Benefits and harms

Microdiscectomy versus conservative treatment:

We found two RCTs comparing microdiscectomy with conservative treatment.[50] [51]

Pain

Compared with conservative treatment Microdiscectomy may be more effective at reducing leg pain intensity at 8 weeks, but may be no more effective at reducing leg or back pain after 6 months to 2 years (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Leg pain
[50]
RCT		 56 people Leg pain, measured on a 100-mm visual analogue scale (VAS) from 0 = no pain to 100 = worst possible pain baseline
61 with microdiscectomy plus physiotherapeutic instructions
57 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
[50]
RCT		 56 people Leg pain, measured on a 100-mm VAS from 0 = no pain to 100 = worst possible pain 6 weeks
12 with microdiscectomy plus physiotherapeutic instructions
25 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
P <0.01 		Effect size not calculated microdiscectomy
[50]
RCT		 56 people Leg pain, measured on a 100-mm VAS from 0 = no pain to 100 = worst possible pain 3 months
9 with microdiscectomy plus physiotherapeutic instructions
16 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
[50]
RCT		 56 people Leg pain, measured on a 100-mm VAS from 0 = no pain to 100 = worst possible pain 6 months
9 with microdiscectomy plus physiotherapeutic instructions
18 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
[50]
RCT		 56 people Leg pain, measured on a 100-mm VAS from 0 = no pain to 100 = worst possible pain 1 year
6 with microdiscectomy plus physiotherapeutic instructions
9 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
[50]
RCT		 56 people Leg pain, measured on a 100-mm VAS from 0 = no pain to 100 = worst possible pain 2 years
6 with microdiscectomy plus physiotherapeutic instructions
15 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation Leg pain, measured on a 100-mm VAS from 0 = no pain to 100 = worst possible pain baseline
67.2 with early microdiscectomy (scheduled within 2 weeks of randomisation)
64.4 with conservative care
Reported as not significant 		Not significant
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation Leg pain, measured on a 100-mm VAS from 0 = no pain to 100 = worst possible pain 8 weeks
10.2 with early microdiscectomy (scheduled within 2 weeks of randomisation)
27.9 with conservative care
Difference 17.7
95% CI 12.3 to 23.1 		Effect size not calculated early microdiscectomy
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation Leg pain, measured on a 100-mm VAS from 0 = no pain to 100 = worst possible pain 6 months
8.4 with early microdiscectomy (scheduled within 2 weeks of randomisation)
14.5 with conservative care
Difference 6.1
95% CI 2.2 to 10.0 		Effect size not calculated early microdiscectomy
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation Leg pain, measured on a 100-mm VAS from 0 = no pain to 100 = worst possible pain 1 year
11.0 with early microdiscectomy (scheduled within 2 weeks of randomisation)
11.0 with conservative care
Difference 0
95% CI –4.0 to +4.0 		Not significant
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation Leg pain, measured on a 100-mm VAS from 0 = no pain to 100 = worst possible pain 2 years
11.0 with early microdiscectomy (scheduled within 2 weeks of randomisation)
9.0 with conservative care
Difference –2
95% CI –6.0 to +2.0 		Not significant
Back pain
[50]
RCT		 56 people Back pain, measured on a 100-mm VAS from 0 = no pain to 100 = worst possible pain baseline
53 with microdiscectomy plus physiotherapeutic instructions
47 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
[50]
RCT		 56 people Back pain, measured on a 100-mm VAS from 0 = no pain to 100 = worst possible pain 6 weeks
21 with microdiscectomy plus physiotherapeutic instructions
28 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
[50]
RCT		 56 people Back pain, measured on a 100-mm VAS from 0 = no pain to 100 = worst possible pain 3 months
15 with microdiscectomy plus physiotherapeutic instructions
22 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
[50]
RCT		 56 people Back pain, measured on a 100-mm VAS from 0 = no pain to 100 = worst possible pain 6 months
13 with microdiscectomy plus physiotherapeutic instructions
20 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
[50]
RCT		 56 people Back pain, measured on a 100-mm VAS from 0 = no pain to 100 = worst possible pain 1 year
19 with microdiscectomy plus physiotherapeutic instructions
17 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
[50]
RCT		 56 people Back pain, measured on a 100-mm VAS from 0 = no pain to 100 = worst possible pain 2 years
11 with microdiscectomy plus physiotherapeutic instructions
21 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation Back pain, measured on a 100-mm VAS from 0 = no pain to 100 = worst possible pain baseline
33.8 with early microdiscectomy (scheduled within 2 weeks of randomisation)
30.8 with conservative care
Reported as not significant 		Not significant
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation Back pain, measured on a 100-mm VAS from 0 = no pain to 100 = worst possible pain 8 weeks
14.4 with early microdiscectomy (scheduled within 2 weeks of randomisation)
25.7 with conservative care
Difference 11.3
95% CI 5.6 to 17.4 		Effect size not calculated microdiscectomy
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation Back pain, measured on a 100-mm VAS from 0 = no pain to 100 = worst possible pain 6 months
15.5 with early microdiscectomy (scheduled within 2 weeks of randomisation)
17.8 with conservative care
Difference +2.3
95% CI –3.6 to +8.2 		Effect size not calculated microdiscectomy
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation Back pain, measured on a 100-mm VAS from 0 = no pain to 100 = worst possible pain 1 year
14.2 with early microdiscectomy (scheduled within 2 weeks of randomisation)
16.5 with conservative care
Difference +2.3
95% CI –3.6 to +8.2 		Effect size not calculated microdiscectomy
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation Back pain, measured on a 100-mm VAS from 0 = no pain to 100 = worst possible pain 2 years
15.9 with early microdiscectomy (scheduled within 2 weeks of randomisation)
17.3 with conservative care
Difference +1.4
95% CI –4.5 to +6.3 		Effect size not calculated Not significant
Short Form-36 bodily pain questionnaire
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation Short Form (SF)-36 bodily pain questionnaire, measured on a scale from 0 to 100; increasing score indicates less-severe symptoms baseline
21.9 with early microdiscectomy (scheduled within 2 weeks of randomisation)
23.9 with conservative care
Reported as not significant 		Not significant
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation SF-36 bodily pain questionnaire, measured on a scale from 0 to 100; increasing score indicates less-severe symptoms 8 weeks
62.8 with early microdiscectomy (scheduled within 2 weeks of randomisation)
54.4 with conservative care
Difference –8.4
95% CI –13.5 to –3.2 		Effect size not calculated microdiscectomy
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation SF-36 bodily pain questionnaire, measured on a scale from 0 to 100; increasing score indicates less-severe symptoms 6 months
76.1 with early microdiscectomy (scheduled within 2 weeks of randomisation)
72.8 with conservative care
Difference –3.3
95% CI –8.4 to +1.8 		Not significant
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation SF-36 bodily pain questionnaire, measured on a scale from 0 to 100; increasing score indicates less-severe symptoms 1 year
81.2 with early microdiscectomy (scheduled within 2 weeks of randomisation)
78.5 with conservative care
Difference –2.7
95% CI –7.9 to +2.6 		Not significant
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation SF-36 bodily pain questionnaire, measured on a scale from 0 to 100; increasing score indicates less-severe symptoms 2 years
78.4 with early microdiscectomy (scheduled within 2 weeks of randomisation)
80.7 with conservative care
Difference +2.3
95% CI –2.7 to +7.3 		Not significant
Open in a new tab

Functional improvement

Compared with conservative treatment We don't know whether microdiscectomy is more effective at improving Oswestry Disability index at 6 weeks to 2 years (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Oswestry Low Back Pain Disability Score
[50]
RCT		 56 people Oswestry Low Back Pain Disability Score, measured on a scale of 0 to 100; increasing score indicates greater lower back pain-related disability baseline
39 with microdiscectomy plus physiotherapeutic instructions
39 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
[50]
RCT		 56 people Oswestry Low Back Pain Disability Score, measured on a scale of 0 to 100; increasing score indicates greater lower back pain-related disability 6 weeks
16 with microdiscectomy plus physiotherapeutic instructions
22 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
[50]
RCT		 56 people Oswestry Low Back Pain Disability Score, measured on a scale of 0 to 100; increasing score indicates greater lower back pain-related disability 3 months
16 with microdiscectomy plus physiotherapeutic instructions
22 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
[50]
RCT		 56 people Oswestry Low Back Pain Disability Score, measured on a scale of 0 to 100; increasing score indicates greater lower back pain-related disability 6 months
8 with microdiscectomy plus physiotherapeutic instructions
12 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
[50]
RCT		 56 people Oswestry Low Back Pain Disability Score, measured on a scale of 0 to 100; increasing score indicates greater lower back pain-related disability 1 year
10 with microdiscectomy plus physiotherapeutic instructions
11 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
[50]
RCT		 56 people Oswestry Low Back Pain Disability Score, measured on a scale of 0 to 100; increasing score indicates greater lower back pain-related disability 2 years
6 with microdiscectomy plus physiotherapeutic instructions
11 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
Modified Roland disability questionnaire
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation Modified Roland disability questionnaire, measured on a scale of 0 to 23; increasing score indicates worse functional status baseline
16.5 with early microdiscectomy (scheduled within 2 weeks of randomisation)
16.3 with conservative care
Reported as not significant 		Not significant
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation Modified Roland disability questionnaire, measured on a scale of 0 to 23; increasing score indicates worse functional status 8 weeks
6.1 with early microdiscectomy (scheduled within 2 weeks of randomisation)
9.2 with conservative care
Difference 3.1
95% CI 1.7 to 4.3 		Effect size not calculated microdiscectomy
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation Modified Roland disability questionnaire, measured on a scale of 0 to 23; increasing score indicates worse functional status 6 months
4.0 with early microdiscectomy (scheduled within 2 weeks of randomisation)
4.8 with conservative care
Difference +0.8
95% CI –0.5 to +2.1 		Not significant
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation Modified Roland disability questionnaire, measured on a scale of 0 to 23; increasing score indicates worse functional status 1 year
3.3 with early microdiscectomy (scheduled within 2 weeks of randomisation)
3.7 with conservative care
Difference +0.4
95% CI –0.9 to +1.7 		Not significant
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation Modified Roland disability questionnaire, measured on a scale of 0 to 23; increasing score indicates worse functional status 2 years
3.1 with early microdiscectomy (scheduled within 2 weeks of randomisation)
2.6 with conservative care
Difference +0.5
95% CI –0.8 to +1.8 		Not significant
Short Form-36 physical functioning questionnaire
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation Short Form (SF)-36 physical functioning questionnaire, measured on a scale from 0 to 100; increasing score indicates less-severe symptoms baseline
33.9 with early microdiscectomy (scheduled within 2 weeks of randomisation)
34.6 with conservative care
Reported as not significant 		Not significant
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation SF-36 physical functioning questionnaire, measured on a scale from 0 to 100; increasing score indicates less-severe symptoms 6 weeks
71.2 with early microdiscectomy (scheduled within 2 weeks of randomisation)
61.9 with conservative care
Difference –9.3
95% CI –14.2 to –4.4 		Effect size not calculated microdiscectomy
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation SF-36 physical functioning questionnaire, measured on a scale from 0 to 100; increasing score indicates less-severe symptoms 6 months
79.1 with early microdiscectomy (scheduled within 2 weeks of randomisation)
77.6 with conservative care
Difference –1.5
95% CI –6.4 to +3.4 		Not significant
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation SF-36 physical functioning questionnaire, measured on a scale from 0 to 100; increasing score indicates less-severe symptoms 1 year
84.2 with early microdiscectomy (scheduled within 2 weeks of randomisation)
82.0 with conservative care
Difference –2.2
95% CI –7.2 to +2.8 		Not significant
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation SF-36 physical functioning questionnaire, measured on a scale from 0 to 100; increasing score indicates less-severe symptoms 2 year
82.3 with early microdiscectomy (scheduled within 2 weeks of randomisation)
83.6 with conservative care
Difference +1.3
95% CI –3.7 to +6.3 		Not significant
Open in a new tab

Quality of life

Compared with conservative treatment We don't know whether microdiscectomy is more effective at 6 weeks to 2 years at improving quality-of-life scores or the subjective ability to work (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Quality of life
[50]
RCT		 56 people Oswestry Low Back Pain Disability Score, measured on a scale of 0 to 100; increasing score indicates greater lower back pain-related disability baseline
0.83 with microdiscectomy plus physiotherapeutic instructions
0.84 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
[50]
RCT		 56 people Oswestry Low Back Pain Disability Score, measured on a scale of 0 to 100; increasing score indicates greater lower back pain-related disability 6 weeks
0.92 with microdiscectomy plus physiotherapeutic instructions
0.89 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
[50]
RCT		 56 people Oswestry Low Back Pain Disability Score, measured on a scale of 0 to 100; increasing score indicates greater lower back pain-related disability 3 months
0.94 with microdiscectomy plus physiotherapeutic instructions
0.91 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
[50]
RCT		 56 people Oswestry Low Back Pain Disability Score, measured on a scale of 0 to 100; increasing score indicates greater lower back pain-related disability 6 months
0.95 with microdiscectomy plus physiotherapeutic instructions
0.90 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
[50]
RCT		 56 people Oswestry Low Back Pain Disability Score, measured on a scale of 0 to 100; increasing score indicates greater lower back pain-related disability 1 year
0.95 with microdiscectomy plus physiotherapeutic instructions
0.94 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
[50]
RCT		 56 people Oswestry Low Back Pain Disability Score, measured on a scale of 0 to 100; increasing score indicates greater lower back pain-related disability 2 years
0.95 with microdiscectomy plus physiotherapeutic instructions
0.93 with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Reported as not significant 		Not significant
Open in a new tab

No data from the following reference on this outcome.[51]

Patient perception of improvement

Compared with conservative treatment Microdiscectomy may be more effective at improving patients' perceived recovery at 8 weeks but may be no more effective at 6 months to 2 years (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Patient perception of improvement
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation Short Form (SF)-36 physical functioning questionnaire, measured on a scale from 0 to 100; increasing score indicates less-severe symptoms 8 weeks
81.2 with early microdiscectomy (scheduled within 2 weeks of randomisation)
36.5 with conservative care
Difference 44.7
95% CI 34.2 to 55.0 		Effect size not calculated microdiscectomy
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation SF-36 physical functioning questionnaire, measured on a scale from 0 to 100; increasing score indicates less-severe symptoms 6 months
77.4 with early microdiscectomy (scheduled within 2 weeks of randomisation)
70.8 with conservative care
Difference +6.6
95% CI –3.7 to +17.0 		Not significant
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation SF-36 physical functioning questionnaire, measured on a scale from 0 to 100; increasing score indicates less-severe symptoms 1 year
85.7 with early microdiscectomy (scheduled within 2 weeks of randomisation)
82.5 with conservative care
Difference +3.2
95% CI –5.4 to +11.9 		Not significant
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation SF-36 physical functioning questionnaire, measured on a scale from 0 to 100; increasing score indicates less-severe symptoms 2 years
81.3 with early microdiscectomy (scheduled within 2 weeks of randomisation)
78.9 with conservative care
Difference +2.4
95% CI –7.2 to +12.0 		Not significant
Open in a new tab

No data from the following reference on this outcome.[50]

Adverse effects

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Adverse effects
[50]
RCT		 56 people Urosepsis
with microdiscectomy plus physiotherapeutic instructions
with conservative treatment (physiotherapeutic instructions plus continued isometric exercises)
Absolute results not reported
[51]
RCT		 283 people with 6 to 12 weeks of persistent sciatica and radiologically confirmed disc herniation Short Form (SF)-36 physical functioning questionnaire, measured on a scale from 0 to 100; increasing score indicates less-severe symptoms 8 weeks
with early microdiscectomy (scheduled within 2 weeks of randomisation)
with conservative care
Absolute results not reported
Open in a new tab

Microdiscectomy versus standard discectomy:

See option on standard discectomy.

Video-assisted arthroscopic microdiscectomy versus standard discectomy:

We found one RCT.[52]

Pain

Compared with standard discectomy We don't know how video-assisted arthroscopic microdiscectomy and standard discectomy compare for reducing pain (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Pain
[52] 60 people with confirmed lumbar disc herniation and associated radiculopathy after failed conservative treatment Mean pain score (visual analogue scale: 0 = no pain, 10 = severe and incapacitating pain) about 31 months
1.2 with video-assisted arthroscopic microdiscectomy
1.9 with standard discectomy
Reported as not significant 		Not significant
Open in a new tab

Patient perception of improvement

Compared with standard discectomy We don't know whether video-assisted arthroscopic microdiscectomy is more effective at increasing the number of people "very satisfied" as measured on a 4-point scale in people with confirmed lumbar disc herniation and associated radiculopathy after failed conservative treatment (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Patient perception of improvement
[52] 60 people with confirmed lumbar disc herniation and associated radiculopathy after failed conservative treatment Proportion of people “very satisfied” on a 4-point satisfaction scale about 31 months
22/30 (73%) with video-assisted arthroscopic microdiscectomy
20/30 (67%) with standard discectomy
RR 1.10
95% CI 0.71 to 1.34 		Not significant
Open in a new tab

Adverse effects

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Adverse effects
[52] 60 people with confirmed lumbar disc herniation and associated radiculopathy after failed conservative treatment Adverse effects
with video-assisted arthroscopic microdiscectomy
with standard discectomy
Open in a new tab

Microdiscectomy versus automated percutaneous discectomy:

See automated percutaneous discectomy.

Further information on studies

Conservative care included prescription of painkillers (details not given), advice to resume daily activities, recommendation of a mobilisation scheme based on time rather than pain (compliance not checked), and referral to a physiotherapist if fearful of movement. Subsequent microdiscectomy was considered for the conservative-care group if sciatica persisted 6 months after randomisation, or earlier (within 6 months) in case of increasing leg pain that was not responsive to drugs and progressive neurological deficit. A total of 125/141 (89%) people in the early microdiscectomy group had microdiscectomy as intended. The remaining 16 people spontaneously recovered. A total of 55/142 (39%) people in the conservative-care group went on to have microdiscectomy in the first year, and one further 7 (5%) had microdiscectomy in the second year after randomisation. The results presented above are based on an intention-to-treat analysis. The interventions in the two groups may have been too similar to detect a significant difference in the outcomes measured at 6 months' to 2 years' follow-up.

The mean duration of postoperative recovery was almost twice as long with open surgery as with microdiscectomy (27 days with microdiscectomy v 49 days with standard discectomy; P value not reported).

Comment

We found one further trial on microsurgery lumbar discectomy that was written in Chinese.[53] We are currently awaiting full text translation and we will assess this for inclusion in our next update.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jun 28;2011:1118.

Standard discectomy

Summary

Both standard discectomy and microdiscectomy seem to increase self-reported improvement to a similar extent.

Benefits and harms

Standard discectomy versus conservative treatment:

We found one systematic review (search date 2007, 2 RCTs).[23]

Pain

Compared with conservative treatment We don't know whether standard discectomy is more effective at improving pain at 1 to 2 years in people with lumbar disc herniation (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Pain
[54]
RCT		 126 people with symptomatic L5/S1 disc herniation
In review [23] 		Proportion of people reporting their improvement as "good" 1 year
39/60 (65%) with standard discectomy
24/66 (36%) with conservative treatment (physiotherapy for 6 weeks)
RR 1.79
95% CI 1.30 to 2.18
NNT 3, 95% CI 2 to 9
Contributors' own calculations 		Small effect size standard discectomy
[54]
RCT		 126 people with symptomatic L5/S1 disc herniation
In review [23] 		Proportion of people reporting their improvement as "good" 4 years
40/60 (67%) with standard discectomy
34/66 (51%) with conservative treatment (physiotherapy for 6 weeks)
RR 1.29
95% CI 0.96 to 1.56
Contributors' own calculations 		Not significant
[54]
RCT		 126 people with symptomatic L5/S1 disc herniation
In review [23] 		Proportion of people reporting their improvement as "good" 10 years
35/60 (58%) with standard discectomy
37/66 (56%) with conservative treatment (physiotherapy for 6 weeks)
RR 1.04
95% CI 0.73 to 1.32
Contributors' own calculations 		Not significant
[55]
RCT		 501 surgical candidates; mean age 42 years; 42% female, with imaging-confirmed lumbar intervertebral disc herniation and at least 6 weeks of radicular symptoms
In review [23] 		Short Form (SF)-36 Bodily Pain mean improvement in pain on a scale from 0 to 100 from baseline 3 months
30.5 with standard open discectomy
27.6 with non-operative treatment
Difference +2.9
95% CI –2.2 to +8.0 		Not significant
[55]
RCT		 501 surgical candidates; mean age 42 years; 42% female, with imaging-confirmed lumbar intervertebral disc herniation and at least 6 weeks of radicular symptoms
In review [23] 		SF-36 Bodily Pain mean improvement in pain on a scale from 0 to 100 from baseline 1 year
39.7 with standard open discectomy
36.9 with non-operative treatment
Difference +2.8
95% CI –2.3 to +7.8 		Not significant
[55]
RCT		 501 surgical candidates; mean age 42 years; 42% female, with imaging-confirmed lumbar intervertebral disc herniation and at least 6 weeks of radicular symptoms
In review [23] 		SF-36 Bodily Pain mean improvement in pain on a scale from 0 to 100 from baseline 2 years
40.3 with standard open discectomy
37.1 with non-operative treatment
Difference +3.2
95% CI –2.0 to +8.4 		Not significant
Open in a new tab

Functional improvement

Compared with conservative treatment We don't know whether standard discectomy is more effective at improving function or Oswestry Disability Index at 1 to 2 years in people with lumbar disc herniation (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Short Form-36 Physical Function scores
[55]
RCT		 501 surgical candidates; mean age 42 years; 42% female, with imaging-confirmed lumbar intervertebral disc herniation and at least 6 weeks of radicular symptoms
In review [23] 		Short Form (SF)-36 Physical Function mean improvement on a scale from 0 to 100 from baseline score 3 months
27.7 with standard open discectomy
24.9 with non-operative treatment
Difference +2.8
95% CI –2.5 to +8.1 		Not significant
[55]
RCT		 501 surgical candidates; mean age 42 years; 42% female, with imaging-confirmed lumbar intervertebral disc herniation and at least 6 weeks of radicular symptoms
In review [23] 		SF-36 Physical Function mean improvement on a scale from 0 to 100 from baseline score 1 year
27.7 with standard open discectomy
24.9 with non-operative treatment
Difference +2.8
95% CI –2.5 to +8.1 		Not significant
[55]
RCT		 501 surgical candidates; mean age 42 years; 42% female, with imaging-confirmed lumbar intervertebral disc herniation and at least 6 weeks of radicular symptoms
In review [23] 		SF-36 Physical Function mean improvement on a scale from 0 to 100 from baseline score 2 years
35.9 with standard open discectomy
35.9 with non-operative treatment
Difference 0
95% CI –5.4 to +5.5 		Not significant
Oswestry Disability Index
[55]
RCT		 501 surgical candidates; mean age 42 years; 42% female, with imaging-confirmed lumbar intervertebral disc herniation and at least 6 weeks of radicular symptoms
In review [23] 		Oswestry Disability Index mean reduction in disability score from baseline on a scale from 0 to 100 3 months
–26.0 with standard open discectomy
–21.3 with non-operative treatment
Difference –4.7
95% CI –9.3 to –0.2 		Effect size not calculated open discectomy
[55]
RCT		 501 surgical candidates; mean age 42 years; 42% female, with imaging-confirmed lumbar intervertebral disc herniation and at least 6 weeks of radicular symptoms
In review [23] 		Oswestry Disability Index mean reduction in disability score from baseline on a scale from 0 to 100 1 year
–30.6 with standard open discectomy
–27.4 with non-operative treatment
Difference –3.2
95% CI –7.8 to +1.3 		Not significant
[55]
RCT		 501 surgical candidates; mean age 42 years; 42% female, with imaging-confirmed lumbar intervertebral disc herniation and at least 6 weeks of radicular symptoms
In review [23] 		Oswestry Disability Index mean reduction in disability score from baseline on a scale from 0 to 100 2 years
–31.4 with standard open discectomy
–28.7 with non-operative treatment
Difference –2.4
95% CI –7.4 to +1.9 		Not significant
Open in a new tab

Adverse effects

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Adverse effects
[55]
RCT		 501 surgical candidates; mean age 42 years; 42% female, with imaging-confirmed lumbar intervertebral disc herniation and at least 6 weeks of radicular symptoms
In review [23] 		Perioperative complications
with standard open discectomy
with non-operative treatment		 Not significant
Open in a new tab

No data from the following reference on this outcome.[54]

Standard discectomy versus epidural corticosteroid injection:

See option on epidural corticosteroid injections.

Standard discectomy versus microdiscectomy:

We found one systematic review (search date 2007, 3 RCTs, 219 people)[23] and two subsequent RCTs[56] [57] comparing standard discectomy versus microdiscectomy. The review did not perform a meta-analysis of the three RCTs because outcomes were not comparable.

Pain

Compared with microdiscectomy We don't know how standard discectomy and microdiscectomy compare at reducing pain in people with herniated disc (very-low quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Pain
[58]
RCT		 60 people with lumbar disc herniation
In review [23] 		Pre- and postoperative pain scores measured on visual analogue scale (VAS)
with standard discectomy
with microdiscectomy
Absolute results not reported
Reported as "similar"
P value not reported
[59]
RCT		 79 people with lumbar disc herniation
In review [23] 		Pain in the legs or back measured on VAS 6 weeks
with standard discectomy
with microdiscectomy
Absolute results not reported
[23]
RCT		 80 people
Data from 1 RCT		 "Clinical outcomes" (not further specified) 15 months
with standard discectomy
with microdiscectomy
Absolute results not reported
Reported as "similar"
Significance not assessed
[56]
RCT		 119 people Mean intensity of sciatic pain scores
1.3 with macrodiscectomy
1.2 with microdiscectomy
P = 0.27 		Not significant
[56]
RCT		 119 people Mean change in Japanese Orthopaedic Association (JOA) score from baseline: scale from −6 to +29; higher scores indicating better outcomes
27 with macrodiscectomy
27 with microdiscectomy
P = 0.08 		Not significant
[57]
RCT		 40 people with sciatica that did not respond to conservative treatment, and posterolateral herniated lumbar disc observed on MRI scans Pain measured on VAS: 0 = no pain, 10 = worst pain ever experienced 24 months
mean 0, range (0−6) with open discectomy
mean 1, range (0−3) with microdiscectomy
P = 0.15 		Not significant
Open in a new tab

Functional improvement

Compared with microdiscectomy Standard discectomy and microdiscectomy may be equally effective at reducing disability and enabling return to work at 1 month (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Oswestry Disability Index
[57]
RCT		 40 people with sciatica that did not respond to conservative treatment, and posterolateral herniated lumbar disc observed on MRI scan Oswestry Disability Index (score range 0−100) 24 months
Median (range) score: 10 (0−30) with open discectomy
Median (range) score: 10 (0−22) with microdiscectomy
P = 0.87 		Not significant
Return to work and normal activities
[57]
RCT		 40 people with sciatica that did not respond to conservative treatment, and posterolateral herniated lumbar disc observed on MRI scans Mean time to return to work and normal activities between groups
21 days with open discectomy
21 days with microdiscectomy
P = 0.79 		Not significant
Open in a new tab

No data from the following reference on this outcome.[23] [56]

Patient perception of improvement

Compared with microdiscectomy Standard discectomy and microdiscectomy seem equally effective at increasing the number of people with lumbar disc herniation who rate their surgeries as "good", "almost recovered", or "totally recovered" at 1 year (moderate-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Patient perception of improvement
[58]
RCT		 60 people with lumbar disc herniation
In review [23] 		Proportion of people who rated their operative outcome as "good", "almost recovered", or "totally recovered" 1 year
26/30 (87%) with standard discectomy
24/30 (80%) with microdiscectomy
RR 1.08
95% CI 0.78 to 1.20
The RCT also found similar changes in both groups in preoperative and postoperative pain scores, and in time taken to return to work (pain scores: visual analogue scale [VAS]; P value not reported; time taken to return to work: 10 weeks in both groups) 		Not significant
Open in a new tab

No data from the following reference on this outcome.[23] [56] [57]

Adverse effects

No data from the following reference on this outcome.[23] [56] [57] [58]

Further information on studies

The RCT comparing standard discectomy versus conservative treatment had considerable crossover between the two treatment groups. Of 66 people randomised to receive conservative treatment, 17 received surgery; of 60 people randomised to receive surgery, one refused the operation. The results presented above are based on an intention-to-treat analysis.

This RCT had nearly 50% crossover in both directions. Of 232 people randomised to surgery and included in the analysis, only 140/232 (60%) had surgery. Of the 240 people randomised to non-operative care and included in the intention-to-treat analysis, 107/204 (52%) had surgery. The 3-year and 4-year follow-up results from this study were published separately. The follow-up at these end points was <80% of randomised participants, so data are not reported above. Similar results for Short Form (SF)-36 scores measuring improvement in pain and Oswestry Disability Index measuring reduction in disability were observed between the group of people who had surgery and the group of people who had non-surgical treatment at both 3 and 4 years.

The RCT analysed the difference in scores between groups after surgery, without comparing the change in score from baseline to end point between groups. The baseline scores for sciatic pain intensity and Japanese Orthopaedic Association scores did not differ significantly at baseline or after surgery. There was, however, a significant difference in leg pain scores at baseline as well as after surgery. Therefore, analysis of the data found neither surgery better than the other.

The RCT stated that only those participants with a final postoperative follow-up period of at least 2 years were included in this study. The RCT reported no information on the number of people who withdrew. It is unclear whether 40 people were originally recruited for the study, or whether this was adjusted based on the follow-up rate.

The RCT also found similar changes in both groups in time taken to return to work (10 weeks in both groups).

Comment

Standard discectomy versus epidural corticosteroid injection:

See comment in epidural corticosteroid injections.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jun 28;2011:1118.

Automated percutaneous discectomy

Summary

We found no clinically important results from RCTs about automated percutaneous discectomy compared with either conservative treatment, standard discectomy, or microdiscectomy.

Benefits and harms

Automated percutaneous discectomy versus conservative treatment:

We found no systematic review or RCTs.

Automated percutaneous discectomy versus standard discectomy:

One systematic review (search date not reported) identified no RCTs comparing automated percutaneous discectomy versus standard discectomy.[61]

Automated percutaneous discectomy versus microdiscectomy:

We found one systematic review (search date 2007),[23] which identified one RCT that met our inclusion criteria.[62] The review did not perform a meta-analysis. One identified RCT did not meet our inclusion criteria due to a high follow-up loss (>20%) and is not discussed further.

Pain

Compared with microdiscectomy Automated percutaneous discectomy may be less effective at increasing treatment success rates (very-low quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Treatment success
[62]
RCT		 71 people with radiographical confirmation of disc herniation Proportion of people with outcome classified as "success" by clinician and masked observer (details not reported)
9/31 (29%) with automated percutaneous discectomy
32/40 (80%) with microdiscectomy
P <0.001
Trial stopped prematurely, after an interim analysis at 6 months 		Effect size not calculated microdiscectomy
Open in a new tab

Adverse effects

No data from the following reference on this outcome.[62]

Further information on studies

None.

Comment

None.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jun 28;2011:1118.

Laser discectomy

Summary

We found no direct information from RCTs about laser discectomy for the treatment of people with symptomatic herniated lumbar disc.

Benefits and harms

Laser discectomy:

Four systematic reviews (search dates not reported,[61] 2007,[23] 2000,[63] and 2009[64]) found no RCTs on the effectiveness of laser discectomy that met Clinical Evidence reporting criteria. One of the reviews[64] identified observational studies, ranging from case reports to large non-randomised studies (see further information on studies).

Further information on studies

This systematic review found many observational studies on percutaneous disc decompression with laser assisted disc removal. Most studies did not meet the quality reporting criteria of the systematic review (lumbar disc pain of at least 3 months' duration; treatment with percutaneous laser disc compression; minimum follow-up of 12 months; at least 50 participants included), but of the 10 that did, all showed a positive effect on pain relief. Several studies reported adverse effects or complications. Overall the most frequently reported complication was spondylodiscitis, which ranged from 0% (4 studies) to 1.2% (1 study). In one study of 164 people, there was 1 case of an instrument tip being faulty, 12 cases of postoperative dermatomal dysaesthesia, and 2 cases of reflex sympathetic dystrophy. In one retrospective study of 658 people, 1.1% reported intraoperative complications and 1.5% reported postoperative complications, including 4 radicular deficits, 3 incidences of L5 nerve root injury, 2 incidences of vascular injuries, 1 incidence of sigmoid artery injury, 1 incidence of anomalous iliolumbar artery injury, and 1 incidence of transverse process injury. There was a case report of subacute cauda equine syndrome.

Comment

None.

Substantive changes

Laser discectomy New evidence added.[64] Categorisation unchanged (Unknown effectiveness), as there remains insufficient evidence to judge the effects of this intervention.

BMJ Clin Evid. 2011 Jun 28;2011:1118.

Percutaneous disc decompression

Summary

We found no direct information from RCTs about percutaneous disc decompression for the treatment of people with symptomatic herniated lumbar disc.

Benefits and harms

Percutaneous disc decompression:

We found one systematic review (search date 2006), which found no RCTs of percutaneous disc decompression for lumbar disc herniation.[65]

Further information on studies

The systematic review also searched for non-experimental descriptive studies, expert opinion, and clinical experience of respected authorities. These data are not included in this review.

Comment

We also found a systematic review on percutaneous disc decompression that was not written in English.[66] We are currently awaiting full text translation and we will assess this for inclusion in our next update.

Substantive changes

No new evidence

Articles from BMJ Clinical Evidence are provided here courtesy of BMJ Publishing Group

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