Intervention Review

Surgical interventions for lumbar disc prolapse

  1. JN Alastair Gibson1,*,
  2. Gordon Waddell2

Editorial Group: Cochrane Back Group

Published Online: 18 APR 2007

Assessed as up-to-date: 6 JAN 2007

DOI: 10.1002/14651858.CD001350.pub4

How to Cite

Gibson JNA, Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD001350. DOI: 10.1002/14651858.CD001350.pub4.

Author Information

  1. 1

    The Royal Infirmary of Edinburgh, Orthopaedic Surgery, Little France, Edinburgh, UK

  2. 2

    University of Cardiff, Centre for Psychosocial & Disability Research, Glasgow, UK

*JN Alastair Gibson, Orthopaedic Surgery, The Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SU, UK. alistair.gibson@luht.scot.nhs.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 18 APR 2007

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

Disc prolapse accounts for five percent of low-back disorders but is one of the most common reasons for surgery.

Objectives

The objective of this review was to assess the effects of surgical interventions for the treatment of lumbar disc prolapse.

Search methods

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, Spine and abstracts of the main spine society meetings within the last five years. We also checked the reference lists of each retrieved articles and corresponded with experts. All data found up to 1 January 2007 are included.

Selection criteria

Randomized trials (RCT) and quasi-randomized trials (QRCT) of the surgical management of lumbar disc prolapse.

Data collection and analysis

Two review authors assessed trial quality and extracted data from published papers. Additional information was sought from the authors if necessary.

Main results

Forty RCTs and two QRCTs were identified, including 17 new trials since the first edition of this review in 1999. Many of the early trials were of some form of chemonucleolysis, whereas the majority of the later studies either compared different techniques of discectomy or the use of some form of membrane to reduce epidural scarring.

Despite the critical importance of knowing whether surgery is beneficial for disc prolapse, only four trials have directly compared discectomy with conservative management and these give suggestive rather than conclusive results. However, other trials show that discectomy produces better clinical outcomes than chemonucleolysis and that in turn is better than placebo. Microdiscectomy gives broadly comparable results to standard discectomy. Recent trials of an inter-position gel covering the dura (five trials) and of fat (four trials) show that they can reduce scar formation, though there is limited evidence about the effect on clinical outcomes. There is insufficient evidence on other percutaneous discectomy techniques to draw firm conclusions. Three small RCTs of laser discectomy do not provide conclusive evidence on its efficacy, There are no published RCTs of coblation therapy or trans-foraminal endoscopic discectomy.

Authors' conclusions

Surgical discectomy for carefully selected patients with sciatica due to lumbar disc prolapse provides faster relief from the acute attack than conservative management, although any positive or negative effects on the lifetime natural history of the underlying disc disease are still unclear. Microdiscectomy gives broadly comparable results to open discectomy. The evidence on other minimally invasive techniques remains unclear (with the exception of chemonucleolysis using chymopapain, which is no longer widely available).

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

The effects of surgical treatments for individuals with 'slipped' lumbar discs

Prolapsed lumbar discs ('slipped disc', 'herniated disc') account for less than five percent of all low-back problems, but are the most common cause of nerve root pain ('sciatica'). Ninety percent of acute attacks of sciatica settle with non-surgical management. Surgical options are usually considered for more rapid relief in the minority of patients whose recovery is unacceptably slow.

This updated review considers the relative merits of different forms of surgical treatments by collating the evidence from 40 randomized trials and two quasi-randomized controlled trials (5197 participants) on:
(i) Discectomy - surgical removal of part of the disc
(ii) Microdiscectomy - use of magnification to view the disc and nerves during surgery
(iii) Chemonucleolysis - injection of an enzyme into a bulging spinal disc in an effort to reduce the size of the disc

Despite the critical importance of knowing whether surgery is beneficial, only three trials directly compared discectomy with non-surgical approaches. These provide suggestive rather than conclusive results. Overall, surgical discectomy for carefully selected patients with sciatica due to a prolapsed lumbar disc appears to provide faster relief from the acute attack than non-surgical management. However, any positive or negative effects on the lifetime natural history of the underlying disc disease are unclear. Microdiscectomy gives broadly comparable results to standard discectomy. There is insufficient evidence on other surgical techniques to draw firm conclusions.

Trials showed that discectomy produced better outcomes than chemonucleolysis, which in turn was better than placebo. For various reasons including concerns about safety, chemonucleolysis is not commonly used today to treat prolapsed disc.

Many trials provided limited information on complications, but generally included recurrence of symptoms, need for additional surgery and allergic reactions (chemonucleolysis).

Many of the trials had major design weaknesses that introduced considerable potential for bias. Therefore, the conclusions of this review should be read with caution.

Future trials should be designed to reduce potential bias. Future research should explore the optimal timing of surgery, patient-centred outcomes, costs and cost-effectiveness of treatment options, and longer-term results over a lifetime perspective.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

腰椎椎間盤突出的外科治療

下背痛的原因有百分之五是椎間盤突出造成,但椎間盤突出是最常見下背痛接受手術治療的原因之ㄧ

目標

這篇文章的目標是評估手術治療對於腰椎椎間盤突出的治療效果

搜尋策略

我們搜尋Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, Spine以及幾個主要脊椎協會五年內的會議摘要,同時也檢視收入文章的參考文獻,並連絡相關專家,所有資料收集到2007年一月一日前的文章

選擇標準

隨機分配或伴隨積分配的腰椎椎間盤突出的手術治療

資料收集與分析

兩位作者評估各篇收入文章的品質及擷取文章中的數據,若有需要會尋求原著作者的額外資料

主要結論

40篇隨機分配的試驗以及兩篇伴隨機分配的試驗,其中包含了1999年本篇文章出版之後的17篇新試驗,許多早期的文章在於探討化學椎間盤溶核術,而大部分晚期的文章比較不同方法的椎間盤切除術或使用某些薄膜以減少硬膜結痂,儘管是否手術治療是較重要的議題,但僅僅有4篇文章直接比較椎間盤切除術與保守治療的效果,而這些文章的最後只給建議而非是結論,其他的文章的結果表示椎間盤切除術比化學椎間盤溶核術有較佳的治療效果,間盤溶核術也比安慰劑效果的治療有效,顯微椎間盤切除術與傳統椎間盤切除比較起兩者的效果相當。近期的文章則討論到凝膠體覆蓋於硬膜外(5篇試驗)以及脂肪覆蓋(4篇試驗)可以減少結痂的形成,但臨床上依然沒有足夠的證據支持上述的覆蓋有較好的效果。目前也沒有證據可以闡述經皮椎間盤切除術的成效,有三篇較小的隨機分配試驗討論雷射椎間盤切除,但沒有提出結論性的證據,關於融切技術或經椎間孔內視鏡椎間盤切除術,目前都還沒有隨機分配的試驗。

作者結論

對於因椎間盤突出造成坐骨神經痛的病人,椎間盤切除手術比保守性治療能較快的減輕急性期的疼痛,但針對本身的椎間盤疾病手術後是否有正向或負向的影響,目前仍沒有清楚的結論。顯微椎間盤切除術和傳統椎間盤切除術廣泛的比較有相當的效果,其他微創方法的效果則還不清楚(使用木瓜凝乳蛋白?的化學椎間盤溶核術則是例外,但此酵素已不再容易得到)

翻譯人

本摘要由臺灣大學附設醫院陳勇璋翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

椎間盤突出佔下背痛原因將近百分之五,但卻是最常見神經根痛(坐骨神經痛)的原因,百分之九十的急性發作僅需要保守性治療,手術治療則常在加速那些恢復速度不如預期的病人身上。本篇綜述性的文章為了評估各種手術治療的相對優點,蒐集了40篇隨機或伴隨機分配的臨床試驗相關文章(共5197位受試者)做比較: (i)椎間盤切除術: 外科手術方式將局部椎間盤切除 (ii)顯微椎間盤切除術: 在術中使用放大效果已清楚看到椎間盤和週遭的神經 (iii) 化學椎間盤溶核術: 注射一種酵素到突出的椎間盤上以減少椎間盤的大小 儘管是否手術治療是較重要的議題,但僅僅有3篇文章直接比較椎間盤切除術與非手術治療的效果,而這些文章的最後只給建議而非是結論。對於因椎間盤突出造成坐骨神經痛的病人,椎間盤切除手術比保守性治療能較快的減輕急性期的疼痛,但針對本身的椎間盤疾病手術後是否有正向或負向的影響,目前仍沒有清楚的結論。顯微椎間盤切除術和傳統椎間盤切除術廣泛的比較有相當的效果,其他微創方法的效果則還不清楚。椎間盤切除術比化學椎間盤溶核術有較佳的治療效果,間盤溶核術也比安慰劑效果的治療有效,然而溶核術因為多種原因包含安全因素較少使用於治療椎間盤突出。很少文章有提到治療後的併發症,最常見的併發症是復發,需要第二次手術,其他相關的併發症有溶核術後的過敏反應。很多文章的設計都有可能造成偏差的弱點,因此本篇文章要做結論應小心謹慎,而之後的研究設計要減少偏差的可能。未來的研究可以著重於手術的時機、病人為主的術後評估、治療的成本、治療的成本效益、以及長時間的結果。