Eur Spine J DOI 10.1007/s00586-012-2422-9 REVIEW ARTICLE Surgical techniques for sciatica due to herniated disc, a systematic review Wilco C. H. Jacobs • Mark P. Arts • Maurits W. van Tulder • Sidney M. Rubinstein • Marienke van Middelkoop • Raymond W. Ostelo • Arianne P. Verhagen • Bart W. Koes • Wilco C. Peul Received: 17 November 2011 / Revised: 1 June 2012 / Accepted: 25 June 2012 Ó The Author(s) 2012. This article is published with open access at Springerlink.com Abstract including chemonucleolysis and prevention of scar tissue or Introduction Disc herniation with sciatica accounts for comparisons against conservative treatment were excluded. five percent of low-back disorders but is one of the most Two review authors independently selected studies, asses- common reasons for spine surgery. The goal of this study sed risk of bias of the studies and extracted data. Quality of was to update the Cochrane review on the effect of surgical evidence was graded according to the GRADE approach. techniques for sciatica due to disc herniation, which was Results Seven studies from the original Cochrane review last updated in 2007. were included and nine additional studies were found. In Materials and methods In April 2011, we conducted total, 16 studies were included, of which four had a low a comprehensive search in CENTRAL, MEDLINE, risk of bias. Studies showed that microscopic discectomy EMBASE, CINAHL, PEDRO, ICL, and trial registries. We results in a significantly, but not clinically relevant longer also checked the reference lists and citation tracking operation time of 12 min (95 % CI 2–22) and shorter results of each retrieved article. Only randomized con- incision of 24 mm (95 % CI 7–40) compared with open trolled trials (RCT) of the surgical management of sciatica discectomy, but did not find any clinically relevant supe- due to disc herniation were included. Comparisons riority of either technique on clinical results. There were conflicting results regarding the comparison of tubular discectomy versus microscopic discectomy for back pain W. C. H. Jacobs (&) W. C. Peul and surgical duration. Department of Neurosurgery,Á Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300 RC Leiden, The Netherlands Conclusions Due to the limited amount and quality of e-mail: [email protected] evidence, no firm conclusions on effectiveness of the cur- rent surgical techniques being open discectomy, micro- M. P. Arts W. C. Peul scopic discectomy, and tubular discectomy compared with DepartmentÁ of Neurosurgery, Medical Center Haaglanden, Lijnbaan 32, 2512 VA The Hague, The Netherlands each other can be drawn. Those differences in leg or back pain scores, operation time, and incision length that were M. W. van Tulder R. W. Ostelo Á found are clinically insignificant. Large, high-quality Department of Health Sciences, Faculty of Earth and Life studies are needed, which examine not only effectiveness Science & EMGO Institute for Health and Care Research, VU University, De Boelelaan 1085, 1081 HV Amsterdam, but cost-effectiveness as well. The Netherlands Keywords Herniated disc Sciatica Surgery M. W. van Tulder S. M. Rubinstein R. W. Ostelo Á Á Á Á Á Discectomy Systematic review Department of Epidemiology and Biostatistics, EMGO-Institute Á for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands Introduction M. van Middelkoop A. P. Verhagen B. W. Koes Department of GeneralÁ Practice, ErasmusÁ MC, University Medical Center Rotterdam, PO Box 2040, Management of sciatica that is caused by a herniated disc 3000 CA Rotterdam, The Netherlands varies considerably. Patients are commonly treated in 123 123 Table 1 Search strings and date limits used for different databases for the updated search Database Search stringsa MEDLINE Randomized Back Pain Discitis Arachnoiditis General Surgery Laminoplasty Foraminotomy Chemonucleolysis controlled trial backache Spinal Diseases (failed adj back) Spinal Fusion Decompression, (forama adj (cauda adj compressa) controlled Low Back (disc adj Cauda Equina Laminectomy Surgical stenosis) discectomy clinical trial Pain degeneration) (lumbar adj vertebraa) Intervertebral (pedicle adj screw) (lumbar adj diskectomy randomized body) (lumbar adj (disc adj (spinal adj stenosis) Disk (facet adj fusion) Laser Therapy placebo pain) prolapse) Displacement (vertebra adj [slipped adj (disca or diska)] (lateral adj mass) Enzymes/tu [Therapeutic drug therapy coccyx (disc adj Bone body) [degenerata adj (disca or [(anterior or posterior) Use] herniation) Transplantation PLIF randomly coccydynia diska)] adj fusion] (enzymea adj injecta) spinal fusion Intervertebral GRAF trial sciatica [stenosis adj (spine or root (bone adj graft) [(intradisca or intradiska) Disk groups spondylosis spinal neoplasms or spinal)] [fixation adj (spinea or ligamentotaxis adj (steroida or Chemolysis [animals not lumbago (facet adj joints) [displacea adj (disca or spinal)] (cage adj fusion) triamcinolone)] a Chymopapain a a (humans and Spine intervertebral disk )] [stabili adj (spine or (screw adj Collagenases/tu animals)] disk a a a Diskectomy spinal)] fusion) [Therapeutic Use] [prolap adj (disc or disk )] a dorsalgia postlaminectomy [(spine or (pedicle adj fusion) (pedicle adj spinal) adj screw) decompressa] laminotomy EMBASE Clinical Article Single Blind [clinic$ adj Random$ Dorsalgia ISCHIALGIA (disc adj Cauda Equina Clinical Study Procedure (study or trial)] [(singl$ or doubl$ or trebl$ back pain spondylosis herniation) spinal stenosis Clinical Trial Phase 3 compar$ or tripl$) adj (blind$ or LOW BACK lumbago spinal fusion spine surgery Clinical mask$)] Controlled control$ PAIN SPINE spinal neoplasms diskectomy Trial trial Study cross?over exp discitis (facet adj joints) discectomy Phase 4 Randomized factorial$ (versus or vs.) BACKACHE intervertebral Clinical exp Spine Disease Intervertebral Disk Controlled human (lumbar adj pain) disk Trial follow?up (disc adj degeneration) Hernia/su [Surgery] Trial Nonhuman coccyx postlaminectomy crossover placebo$ (disc adj prolapse) Clinical Study procedure prospectiv$ exp ANIMAL coccydynia arachnoiditis Double Blind placebo Animal Experiment sciatica (failed adj back) Procedure allocat$ Multicenter Study assign$ blind$ CINAHL Back Leg Back Pain Back Injuries Low Back Pain Sciatica (low next back lbp Buttocks next pain) Eur Spine J Eur Spine J Table 1 continued Database Search stringsa CENTRAL Back Pain Spine Facet near joints Degenerata near (disca or Intervertebral Lateral near mass Lumbar near Chemonucleolysis a dorsalgia Spinal Intervertebral disk ) Disk anterior or posterior) body cauda adj compressa Chemolysis backache Diseases Disk stenosis near (spine or root near fusion vertebra near Laser Therapy or spinal) Chymopapain body Low Back Pain Lumbago postlaminectomy bone near graft (discectomy) or displacea near (disca or Diskectomy a PLIF lumbar next Discitis arachnoiditis fixation near (spine or (diskectomy) diska) pain disc near failed near back Decompression, spinal) GRAF Enzymes prolapa near (disca or diska) Surgical a a coccyx degeneration Cauda Equina stabili near (spine or Ligamentotaxis Collagenases Surgery (spinea or spinal) spinal) coccydynia disc near lumbar near cage near fusion enzymea near injecta near prolapse vertebraa Spinal Fusion pedicle near fusion screw near a a spondylosis decompressa (intradisc or intradisk ) disc near spinal near Laminectomy foraminotomy fusion near (steroida or Sciatica Laminotomy herniation stenosis Intervertebral Disk forama near stenosis pedicle adj triamcinolone) Laminoplasty spinal fusion slipped near Displacement screw spinal (disca or diska) Bone Transplantation pedicle near neoplasms screw facet near fusion PEDro Clinical Trial Randoma Versus ‘‘controlled trial’’ Single-blind ‘‘BACK PAIN’’ ‘‘SCIATICA’’ Sciatica :Controlled placeboa vs double-blind ‘‘single blind’’ ‘‘LOW BACK PAIN’’ ‘‘low back pain’’ ‘‘LUMBOSACRAL Clinical Trial sham ‘‘clinical trial’’ ‘‘double blind’’ ‘‘BACK’’ ‘‘LUMBAR SPINE’’ ‘‘back pain’’ REGION’’ Randomized ‘‘LUMBAR Controlled VERTEBRAE’’ Trial a For readability we omitted connectors, search fields, explode options and multiple versions of the same search term in one database 123 Eur Spine J Table 2 Selection criteria Types of studies Randomized controlled trials (RCT) No fatal methodological flaw Full-text journal article Published in a peer reviewed journal Types of participants Patients with sciatica due to disc herniation, who have indications for surgical intervention Types of interventions Comparisons between all types of surgical intervention were included, such as discectomy, micro-endoscopic- discectomy, automated percutaneous discectomy, nucleoplasty and laser discectomy. Any modifications to these interventional procedures were included, but alternative therapies such as nutritional or hormonal therapies were excluded Types of outcome All available outcomes were included, but patient centered outcomes were considered of primary interest: measures Pain (Average on VAS or similar, or proportion improved) Recovery (Proportion of patients reporting recovery and/or as determined by a clinician) Function (Proportion of patients who had an improvement in function measured on a disability or quality of life scale) Return to work Rate of subsequent low back surgery Measures of objective physical impairment: Spinal flexion, improvement in straight leg raise, alteration in muscle power and change in neurological signs Adverse complications: Early: Damage to spinal cord, cauda equina, dural lining, a nerve