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Meta-Analysis
. 2007 Apr 18;2007(2):CD001350.
doi: 10.1002/14651858.CD001350.pub4.

Surgical interventions for lumbar disc prolapse

J N A Gibson  1 , G Waddell
Affiliations
Meta-Analysis

Surgical interventions for lumbar disc prolapse

J N A Gibson et al. Cochrane Database Syst Rev. .

Abstract

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 strategy: 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).

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Conflict of interest statement

None known

Figures

1.1
1.1. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 1 No success at 6 wks ‐ patient rated.
1.2
1.2. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 2 No success at 6 mths ‐ patient rated.
1.3
1.3. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 3 No success at 1 yr plus ‐ patient rated.
1.4
1.4. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 4 No success at 2 yrs ‐ patient rated.
1.5
1.5. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 5 No success at 10 yrs ‐ patient rated.
1.6
1.6. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 6 No success at 6 wks ‐ surgeon rated.
1.7
1.7. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 7 No success at 3 mths ‐ surgeon rated.
1.8
1.8. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 8 No success at 6 mths ‐ surgeon rated.
1.9
1.9. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 9 No success at 1 yr ‐ surgeon rated.
1.10
1.10. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 10 No success at 2yrs ‐ surgeon rated.
1.11
1.11. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 11 No success at 10 yrs ‐ surgeon rated.
1.12
1.12. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 12 No success at 3 mths ‐ independent observer rated.
1.13
1.13. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 13 No success at 6 mths ‐ independent observer rated.
1.14
1.14. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 14 No success at 3‐12 mths ‐ independent observer rated.
1.15
1.15. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 15 2nd procedure needed within 1 yr.
1.16
1.16. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 16 2nd procedure needed 6‐24mths.
1.17
1.17. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 17 2nd procedure needed within 10 yrs.
1.18
1.18. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 18 Code break within 6 mths.
1.19
1.19. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 19 No improvement in back pain at 4 to 6 weeks.
1.20
1.20. Analysis
Comparison 1 CHYMOPAPAIN V. PLACEBO, Outcome 20 No improvement in sciatica at 42 to 90 days.
2.1
2.1. Analysis
Comparison 2 DISCECTOMY V. CHYMOPAPAIN, Outcome 1 Condition unchanged/worse at 1 yr ‐ patient rated.
2.2
2.2. Analysis
Comparison 2 DISCECTOMY V. CHYMOPAPAIN, Outcome 2 Poor outcome obtained at 1 yr ‐ surgeon rated.
2.3
2.3. Analysis
Comparison 2 DISCECTOMY V. CHYMOPAPAIN, Outcome 3 Mediocre/bad result at 2 yrs ‐ surgeon rated.
2.4
2.4. Analysis
Comparison 2 DISCECTOMY V. CHYMOPAPAIN, Outcome 4 No success at 2 yrs ‐ independent observer rated.
2.5
2.5. Analysis
Comparison 2 DISCECTOMY V. CHYMOPAPAIN, Outcome 5 2nd procedure needed within 1 yr.
2.6
2.6. Analysis
Comparison 2 DISCECTOMY V. CHYMOPAPAIN, Outcome 6 2nd procedure needed within 2 yrs.
2.7
2.7. Analysis
Comparison 2 DISCECTOMY V. CHYMOPAPAIN, Outcome 7 2nd procedure within 1‐2 years.
3.1
3.1. Analysis
Comparison 3 DISCECTOMY V. CHYMOPAPAIN PLUS DISCECTOMY IF NECESSARY, Outcome 1 Unsatisfactory at 1 yr without second surgery ‐ patient rated.
3.2
3.2. Analysis
Comparison 3 DISCECTOMY V. CHYMOPAPAIN PLUS DISCECTOMY IF NECESSARY, Outcome 2 Unsatisfactory at 1 year after all treatments ‐ patient rated.
3.3
3.3. Analysis
Comparison 3 DISCECTOMY V. CHYMOPAPAIN PLUS DISCECTOMY IF NECESSARY, Outcome 3 Unsatisfactory at 1 year without second surgery ‐ physician rated.
3.4
3.4. Analysis
Comparison 3 DISCECTOMY V. CHYMOPAPAIN PLUS DISCECTOMY IF NECESSARY, Outcome 4 2nd procedure needed within 1 yr.
4.1
4.1. Analysis
Comparison 4 AUTOMATED PERCUTANEOUS DISCECTOMY V. CHYMOPAPAIN, Outcome 1 No success at 1 yr ‐ patient rated.
4.2
4.2. Analysis
Comparison 4 AUTOMATED PERCUTANEOUS DISCECTOMY V. CHYMOPAPAIN, Outcome 2 2nd procedure needed within 1 yr.
5.1
5.1. Analysis
Comparison 5 COLLAGENASE V. CHYMOPAPAIN, Outcome 1 Fair or poor outcome at 1 yr ‐ surgeon rated.
5.2
5.2. Analysis
Comparison 5 COLLAGENASE V. CHYMOPAPAIN, Outcome 2 2nd treatment needed within 3 yrs.
5.3
5.3. Analysis
Comparison 5 COLLAGENASE V. CHYMOPAPAIN, Outcome 3 Fair or poor outcome at 5 years.
6.1
6.1. Analysis
Comparison 6 STEROID V. CHYMOPAPAIN, Outcome 1 Failure / No improvement ‐ independent observer rated.
6.2
6.2. Analysis
Comparison 6 STEROID V. CHYMOPAPAIN, Outcome 2 2nd procedure needed between 6‐24 mths.
7.1
7.1. Analysis
Comparison 7 LOW‐DOSE V. STANDARD DOSE CHYMOPAPAIN, Outcome 1 No success at 30 days ‐ patient rated.
7.2
7.2. Analysis
Comparison 7 LOW‐DOSE V. STANDARD DOSE CHYMOPAPAIN, Outcome 2 No success at 1 yr ‐ surgeon rated.
8.1
8.1. Analysis
Comparison 8 COLLAGENASE V. PLACEBO, Outcome 1 Poor result obtained at 17 mths ‐ patient rated.
9.1
9.1. Analysis
Comparison 9 COLLAGENASE INTRAPROTRUSION V. INTRADISK, Outcome 1 No effect.
10.1
10.1. Analysis
Comparison 10 MICRO. V. STANDARD DISCECTOMY, Outcome 1 Condition unchanged / worse at 1 yr ‐ patient rated.
10.2
10.2. Analysis
Comparison 10 MICRO. V. STANDARD DISCECTOMY, Outcome 2 Poor outcome 12‐18 mths ‐ independent assessor rated.
11.1
11.1. Analysis
Comparison 11 DISCECTOMY V. CONSERVATIVE ± DISCECTOMY, Outcome 1 Poor/bad result at 1 yr ‐ surgeon rated.
11.2
11.2. Analysis
Comparison 11 DISCECTOMY V. CONSERVATIVE ± DISCECTOMY, Outcome 2 Poor/bad result at 4 yrs ‐ surgeon rated.
11.3
11.3. Analysis
Comparison 11 DISCECTOMY V. CONSERVATIVE ± DISCECTOMY, Outcome 3 Poor/bad result at 10 yrs ‐ surgeon rated.
11.4
11.4. Analysis
Comparison 11 DISCECTOMY V. CONSERVATIVE ± DISCECTOMY, Outcome 4 Oswestry disability index.
12.1
12.1. Analysis
Comparison 12 PERCUTANEOUS ENDOSCOPIC DISCECTOMY (ANY TYPE) V. MICRODISCECTOMY, Outcome 1 Poor result at 6 mos to 2 yrs ‐ pt rated.
12.2
12.2. Analysis
Comparison 12 PERCUTANEOUS ENDOSCOPIC DISCECTOMY (ANY TYPE) V. MICRODISCECTOMY, Outcome 2 Failure at 6 mths ‐ Independent observer rated (Automated alone).
12.3
12.3. Analysis
Comparison 12 PERCUTANEOUS ENDOSCOPIC DISCECTOMY (ANY TYPE) V. MICRODISCECTOMY, Outcome 3 Repeat surgery needed within 6 mths.
12.4
12.4. Analysis
Comparison 12 PERCUTANEOUS ENDOSCOPIC DISCECTOMY (ANY TYPE) V. MICRODISCECTOMY, Outcome 4 SF‐36 Physical Functioning.
13.1
13.1. Analysis
Comparison 13 PERCUTANEOUS ENDOSCOPIC DISCECTOMY (ANY TYPE) AND SUBSEQUENT MICRODISCECTOMY IF FAILURE V. MICRODISCECTOMY, Outcome 1 No success at 2 yrs ‐ Patient rated.
13.2
13.2. Analysis
Comparison 13 PERCUTANEOUS ENDOSCOPIC DISCECTOMY (ANY TYPE) AND SUBSEQUENT MICRODISCECTOMY IF FAILURE V. MICRODISCECTOMY, Outcome 2 No success at 1yr ‐ Independent observer rated.
14.1
14.1. Analysis
Comparison 14 LASER DISCECTOMY ‐V‐ CHYMOPAPAIN, Outcome 1 Secondary surgery.
14.2
14.2. Analysis
Comparison 14 LASER DISCECTOMY ‐V‐ CHYMOPAPAIN, Outcome 2 Failure at unknown time.
15.1
15.1. Analysis
Comparison 15 GELFOAM V. NO INTERPOSITION MEMBRANE, Outcome 1 Poor result at 1yr ‐ independent observer rated.
15.2
15.2. Analysis
Comparison 15 GELFOAM V. NO INTERPOSITION MEMBRANE, Outcome 2 Moderate scar formation (MRI assessment).
16.1
16.1. Analysis
Comparison 16 FREE FAT GRAFT V. NO INTERPOSITION MEMBRANE, Outcome 1 Poor result at 1yr ‐ observer rated.
16.2
16.2. Analysis
Comparison 16 FREE FAT GRAFT V. NO INTERPOSITION MEMBRANE, Outcome 2 Severe scar formation (MRI/ CT assessment).
16.3
16.3. Analysis
Comparison 16 FREE FAT GRAFT V. NO INTERPOSITION MEMBRANE, Outcome 3 Poor result ‐ patient rated at 1or 2 years.
17.1
17.1. Analysis
Comparison 17 VIDEO‐ASSISTED ARTHROSCOPIC MICRODISCECTOMY V. OPEN DISCECTOMY, Outcome 1 Poor result ‐ Surgeon rated at 2 years.
17.2
17.2. Analysis
Comparison 17 VIDEO‐ASSISTED ARTHROSCOPIC MICRODISCECTOMY V. OPEN DISCECTOMY, Outcome 2 Poor result ‐ patient rated at 2 years.
18.1
18.1. Analysis
Comparison 18 ADCON‐L GEL V. NO INTERPOSITION MEMBRANE, Outcome 1 Roland & Morris Disability Score (US results).
18.2
18.2. Analysis
Comparison 18 ADCON‐L GEL V. NO INTERPOSITION MEMBRANE, Outcome 2 Scarring on MRI (>75% in most involved segment) at 12 months (European results).
18.3
18.3. Analysis
Comparison 18 ADCON‐L GEL V. NO INTERPOSITION MEMBRANE, Outcome 3 Scarring on MRI (>75% in most involved segment) at 6 months.
18.4
18.4. Analysis
Comparison 18 ADCON‐L GEL V. NO INTERPOSITION MEMBRANE, Outcome 4 Poor result ‐ patient rating (US results).
18.5
18.5. Analysis
Comparison 18 ADCON‐L GEL V. NO INTERPOSITION MEMBRANE, Outcome 5 Failure to return to work at 6 months (US results).
18.6
18.6. Analysis
Comparison 18 ADCON‐L GEL V. NO INTERPOSITION MEMBRANE, Outcome 6 Re‐operation at 6 months (US results).
18.7
18.7. Analysis
Comparison 18 ADCON‐L GEL V. NO INTERPOSITION MEMBRANE, Outcome 7 Reoperation at 6 months (European results).
18.8
18.8. Analysis
Comparison 18 ADCON‐L GEL V. NO INTERPOSITION MEMBRANE, Outcome 8 Adverse events at 6 months.
19.1
19.1. Analysis
Comparison 19 POLYLACTIC ACID V. NO INTERPOSITION MEMBRANE, Outcome 1 Surgeon rating at 6 months.
20.1
20.1. Analysis
Comparison 20 DIODE LASER V. Nd‐YAG LASER FOR DISCECTOMY, Outcome 1 Repeat surgery.
21.1
21.1. Analysis
Comparison 21 SEQUESTRECTOMY V. MICRODISCECTOMY, Outcome 1 Operating time.
21.2
21.2. Analysis
Comparison 21 SEQUESTRECTOMY V. MICRODISCECTOMY, Outcome 2 Repeat surgery at 18 months.
21.3
21.3. Analysis
Comparison 21 SEQUESTRECTOMY V. MICRODISCECTOMY, Outcome 3 Not satisfied at 6 months.
21.4
21.4. Analysis
Comparison 21 SEQUESTRECTOMY V. MICRODISCECTOMY, Outcome 4 Poor or Moderate rating at 6 months.
22.1
22.1. Analysis
Comparison 22 MICRODISCECTOMY V. EPIDURAL STEROID, Outcome 1 Failure of Epidural Injection.
23.1
23.1. Analysis
Comparison 23 MICROENDOSCOPIC DISCECTOMY V. OPEN DISCECTOMY, Outcome 1 Unsatisfied ‐ patient rating.
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Update of

References

References to studies included in this review

Benoist 1993 {published data only}
    1. Benoist M, Bonneville JF, Lassale B, Runge M, Gillard C, Vazquez Suarez J, et al. A randomized, double‐blind study to compare low‐dose with standard‐dose chymopapain in the treatment of herniated lumbar intervertebral discs. Spine 1993;18(1):28‐34. - PubMed
Bernsmann 2001 {published data only}
    1. Bernsmann K, Kramer J, Ziozios I, Wehmeier J, Wiese M. Lumbar micro disc surgery with and without autologous fat graft. Arch Orthop Trauma Surg 2001;121:476‐80. - PubMed
Bontoux 1990 {published data only}
    1. Bontoux D, Alcalay M, Debiais F, Garrouste O, Ingrand P, Azais I, et al. Treatment of lumbar disk hernia by intra‐disk injection of chymopapain or triamcinolone hexacetonide. Comparative study of 80 cases [Traitement des hernies discales lombaires par injection intradiscale de chymopapaine ou d'hexacetonide de triamcinolone. Etude comparee de 80 cases]. Rev Rhum Mal Osteoartic 1990;57(4):327‐31. - PubMed
Bourgeois 1988 {published data only}
    1. Bourgeois P, Benoist M, Palazzo E, Belmatoug N, Folinais D, Frot B, et al. Multicenter randomized double‐blind study of triamcinolone hexacetonide versus chymopapain in the treatment of disk lumbosciatica. Initial results at 6 months [Etude en double aveugle randomisee multicentrique de l'hexacetonide de triamcinolone versus chymopapaine dans le traitement de la lombosciatique discale. Premiers resultats a six mois]. Rev Rhum Mal Osteoartic 1988;55(10):767‐9. - PubMed
Bromley 1984 {published data only}
    1. Bromley JW, Varma AO, Santoro AJ, Cohen P, Jacobs R, Berger L. Double‐blind evaluation of collagenase injections for herniated lumbar discs. Spine 1984;9(5):486‐8. - PubMed
Butterman 2004 {published data only}
    1. Butterman GR. Treatment of lumbar disc herniation: epidural steroid injection compared with discectomy. J Bone Joint Surg 2004;86‐A:670‐9. - PubMed
Chatterjee 1995 {published data only}
    1. Chatterjee S, Foy PM, Findlay GF. Report of a controlled clinical trial comparing automated percutaneous lumbar discectomy and microdiscectomy in the treatment of contained lumbar disc herniation. Spine 1995;20(6):734‐8. - PubMed
    1. Stevenson RC, McCabe CJ, Findlay AM. An economic evaluation of a clinical trial to compare automated percutaneous lumbar discectomy with microdiscectomy in the treatment of contained lumbar disc herniation. Spine 1995;20(6):739‐42. - PubMed
Crawshaw 1984 {published data only}
    1. Crawshaw C, Frazer AM, Merriam WF, Mulholland RC, Webb JK. A comparison of surgery and chemonucleolysis in the treatment of sciatica. A prospective randomized trial. Spine 1984;9(2):195‐8. - PubMed
Dabezies 1988 {published data only}
    1. Dabezies EJ, Langford K, Morris J, Shields CB, Wilkinson HA. Safety and efficacy of chymopapain (Discase) in the treatment of sciatica due to a herniated nucleus pulposus. Results of a randomized, double‐blind study. Spine 1988;13(5):561‐5. - PubMed
De Tribolet 1998 {published data only}
    1. Tribolet N, Porchet F, Lutz TW, Gratzl O, Brotchi J, Alphen A, et al. Clinical assessment of a novel antiadhesion barrier gel: prospective, randomised multicenter clinical trial of ADCON‐L to inhibit postoperative peridural fibrosis and related symptoms after lumbar discectomy. Am J Orth 1998;27(2):111‐20. - PubMed
Ejeskar 1983 {published data only}
    1. Ejeskar A, Nachemson A, Herberts P, Lysell E, Andersson G, Irstam L, et al. Surgery versus chemonucleolysis for herniated lumbar discs. A prospective study with random assignment. Clin Orthop 1983;174:236‐42. - PubMed
Feldman 1986 {published data only}
    1. Feldman J, Menkes CJ, Pallardy G, Chevrot A, Horreard P, Zenny JC, et al. Double‐blind study of the treatment of disc lumbosciatica by chemonucleolysis [Etude en double‐aveugle du traitement de la lombosciatique discale par chimionucleolyse]. Rev Rhum Mal Osteoartic 1986;53(3):147‐52. - PubMed
Fraser 1982 {published data only}
    1. Fraser RD. Chymopapain for the treatment of intervertebral disc herniation. A preliminary report of a double‐blind study. Spine 1982;7(6):608‐12. - PubMed
    1. Fraser RD. Chymopapain for the treatment of intervertebral disc herniation. The final report of a double‐blind study. Spine 1984;9(8):815‐8. - PubMed
    1. Gogan WJ, Fraser RD. Chymopapain. A 10‐year, double‐blind study. Spine 1992;17(4):388‐94. - PubMed
Gambardella 2005 {published data only}
    1. Gambardella G, Gervasio O, Zaccone C, Puglisi E. Prevention of recurrent radicular pain after lumbar disc surgery: A prospective study. Acta Neurochir 2005;92:151‐4. - PubMed
Geisler 1999 {published data only}
    1. Geisler FH. Prevention of peridural fibrosis: Current methodologies. Neurological Research 1999;21(Supplement 1):S9‐S22. - PubMed
    1. McKinley DS, Shaffer LM. Cost effectiveness evaluation of ADCON‐L adhesion control gel in lumbar surgery. Neurological Research 1999;21(Supplement 1):S67‐71. - PubMed
    1. Petrie JL, Ross JS. Use of ADCON‐L to inhibit postoperative peridural fibrosis and related symptoms following lumbar disc surgery: A preliminary report. Eur Spine J 1996;5:S10‐17. - PubMed
Greenfield 2003 {published data only}
    1. Greenfield K, Nelson RJ, Findlay GD, Egger M, Sanford E. Microdiscectomy and conservative treatment for lumbar disc herniation with back pain and sciatica: a randomised clinical trial. Proceedings of the International Society for the Study of the Lumbar Spine. 2003:245.
Haines 2002 {published data only}
    1. Haines SJ, Jordan N, Boen JR, Nyman JA, Oldridge NB, Lindgren BR. Discectomy strategies for lumbar disc herniation: Results of the LAPDOG trial. J Clin Neuroscience 2002;9(4):411‐7. - PubMed
Hedtmann 1992 {published data only}
    1. Hedtmann A, Fett H, Steffen R, Kramer J. Chemonucleolysis and percutaneous discotomy ‐ value in treatment of lumbar intervertebral disk displacement. Aktuelle probleme in chirurgie und orthopadie 1994;43:156‐65. - PubMed
    1. Hedtmann A, Fett H, Steffen R, Kramer J. Chemonucleolysis using chymopapain and collagenase. 3‐year results of a prospective randomized study [Chemonukleolyse mit Chymopapain und Kollagenase. 3‐Jahres‐Ergebnisse einer prospektiv‐randomisierten Studie]. Z Orthop Ihre Grenzgeb 1992;130(1):36‐44. - PubMed
    1. Wittenberg RH, Oppel S, Rubenthaler FA, Steffen R. Five‐year results from chemonucleolysis with chymopapain or collagenase. Spine 2001;26(17):1835‐41. - PubMed
    1. Wittenberg RH, Oppel SC, Steffen R. Intradiscal therapy with chymopapain or collagenase: Five year results of a prospective randomized investigation. Orthop Trans. 1996‐7; Vol. 20:1064‐5.
Henriksen 1996 {published data only}
    1. Henrikson L, Schmidt V, Eskesen V, Jantzen E. A controlled study of microsurgical versus standard lumbar discectomy. Br J Neurosurg 1996;10:289‐93. - PubMed
Hermantin 1999 {published data only}
    1. Hermantin FU, Peters T, Quartararo L, Kambin P. A prospective, randomized study comparing the results of open discectomy with those of video‐assisted arthroscopic microdiscectomy. J Bone Joint Surg 1999;81‐A(7):958‐65. - PubMed
Huang 2004 {published data only}
    1. Huang J‐J, Song Y‐M, Liu L‐M. Clinical study of prevention of epidural scar and adhesion with polylactic acid membrane. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2004;18:21‐4. - PubMed
Huang 2005 {published data only}
    1. Huang T‐J, Hsu R W‐W, Li Y‐Y. Less systemic cytokine response in patients following microendoscopic versus open lumbar discectomy. J Orth Res 2005;23(2):406‐11. - PubMed
Javid 1983 {published data only}
    1. Javid MJ, Nordby EJ, Ford LT, Hejna WJ, Whisler WW, Burton C, et al. Safety and efficacy of chymopapain (chymodiactin) in herniated nucleus pulposus with sciatica. Journal of the American Medical Association 1983;249(18):2489‐94. - PubMed
    1. Schenk K‐D, Freischutz G. Clinical testing of Chymodiactin and post‐marketing surveillance. Neurochirurgia 1986;29:167‐72. - PubMed
Jensen 1996 {published data only}
    1. Jensen TT, Asmussen K, Berg‐Hansen E‐MB, Lauritsen B, Manniche C, Vinterberg H, et al. First‐time operation for lumbar disc herniation with or without free fat transplantation. Prospective triple‐blind randomized study with reference to clinical factors and enhanced computed tomographic scan 1 year after operation. Spine 1996;21:1072‐6. - PubMed
    1. Jensen TT, Asmussen KH, Rose‐Hansen EB, Lauritsen BU, Manniche C, Vinterberg H, et al. Lumbar disc prolapse operation with or without free fat transplantation. Prospective triple blind randomized study [Lumbal diskusprolaps‐operation med eller uden fri fedt‐transplantation. Prospektivt tripelblindt randomiseret studie]. Ugeskrift for Laeger 1997;159(14):2091‐5. - PubMed
Kim 2004 {published data only}
    1. Kim KD, Wang JC, Robertson DP, Brodke DS, BenDebba M, Block KM, et al. Reduction in leg pain and lower‐ extremity weakness with Oxiplex/SP Gel for 1 year after laminectomy, laminotomy and discectomy. Neurosurg Focus 2004;17(1):1‐6. - PubMed
Krugluger 2000 {published data only}
    1. Krugluger J, Eberl V, Knahr K. Intermediate results of a prospective randomised comparison of chemonucleolysis and percutaneous discectomy. J Bone Joint Surg. 1997; Vol. 79‐B:247.
    1. Krugluger J, Knahr K. Chemonucleolysis and automated percutaneous discectomy ‐ a prospective randomized comparison. International Orthopaedics (SICOT) 2000;24:167‐9. - PMC - PubMed
Lagarrigue 1994 {published data only}
    1. Lagarrigue J, Chaynes P. Comparative study of disk surgery with or without microscopy. A prospective study of 80 cases [Etude comparative de la chirurgie discale avec et sans microscope]. Neurochirurgie 1994;40(2):116‐20. - PubMed
Lavignolle 1987 {published data only}
    1. Lavignolle B, Vital JM, Baulny D, Grenier F, Castagnera L. Comparative study of surgery and chemonucleolysis in the treatment of sciatica caused by a herniated disk [Etudes comparees de la chirurgie et de la chimionucleolyse dans le traitement de la sciatique par hernie discale]. Acta Orthop Belg 1987;53(2):244‐9. - PubMed
MacKay 1995 {published data only}
    1. MacKay MA, Fischgrund JS, Herkowitz HN, Kurz LT, Hecht B, Schwartz M. The effect of interposition membrane on the outcome of lumbar laminectomy and discectomy. Spine 1995;20:1793‐6. - PubMed
Mayer 1993 {published data only}
    1. Malter AD, Larson EB, Urban N, Deyo RA. Cost‐effectiveness of lumbar discectomy for the treatment of herniated inter‐vertebral disc. Spine 1996;21:1048‐55. - PubMed
    1. Mayer HM, Brock M. Percutaneous endoscopic discectomy: surgical technique and preliminary results compared to microsurgical discectomy. J Neurosurg 1993;78(2):216‐25. - PubMed
Muralikuttan 1992 {published data only}
    1. Muralikuttan KP, Hamilton A, Kernohan WG, Mollan RA, Adair IV. A prospective randomized trial of chemonucleolysis and conventional disc surgery in single level lumbar disc herniation. Spine 1992;17(4):381‐7. - PubMed
Paul 2000 {published data only}
    1. Hellinger J. [Non‐endoskopische perkutane laser‐diskusdekompression und nukleotomie]. Medizim im bild 1995;5:49‐56.
    1. Paul M, Hellinger J. Nd‐YAG (1064nm) versus diode (940nm) PLDN: a prospective randomised blinded study. Proceedings of the First Interdisciplinary World Congress on Spinal Surgery and related disciplines. 2000:555‐8.
Revel 1993 {published data only}
    1. Revel M, Payan C, Vallee C, Laredo JD, Lassale B, Roux C, et al. Automated percutaneous lumbar discectomy versus chemonucleolysis in the treatment of sciatica. A randomized multicenter trial. Spine 1993;18(1):1‐7. - PubMed
Richter 2001 {published data only}
    1. Richter H, Kast E, Tomczak R, Besenfelder W, Gaus W. Results of applying ADCON‐L gel after lumbar discectomy: the German ADCON‐L study. Journal of Neurosurgery 2001;95(2 Suppl):179‐89. - PubMed
Schwetschenau 1976 {published data only}
    1. Martins AN, Ramirez A, Johnston J, Schwetschenau PR. Double blind evaluation of chemonucleolysis for herniated lumbar discs. Late results. J Neurosurg 1978;49:816‐27. - PubMed
    1. Schwetschenau R, Ramirez A, Johnston J, Barnes E, Wiggs C, Martins AN. Double‐blind evaluation of intradiscal chymopapain for herniated lumbar discs. Early results. J Neurosurg 1976;45:622‐7. - PubMed
Steffen 1996 {published data only}
    1. Steffen R, Luetke A, Wittenberg RH, Kraemer J. A prospective comparative study of chemonucleolysis and laser discectomy. Orthop Trans. 1996; Vol. 20:388.
    1. Steffen R, Wittenberg RH, Kraemer J. Chemonucleolysis versus laser disc decompression ‐ a prospective randomised trial. J Bone Joint Surg. 1997; Vol. 79‐B:247.
Thome 2005 {published data only}
    1. Thome C, Barth M, Scharf J, Schmiedek P. Outcome after lumbar sequestrectomy compared with microdiscectomy: A prospective randomized study. J Neurosurg Spine 2005;2:271‐8. - PubMed
Tullberg 1993 {published data only}
    1. Tullberg T. Lumbar disc herniation: results of micro and standard surgical treatment evaluated by clinical, radiological and neurophysiological methods. St. Goran Hospital and Karolinsk Hospital, Stockholm (thesis), 1993.
    1. Tullberg T, Isacson J, Weidenhielm L. Does microscopic removal of lumbar disc herniation lead to better results than the standard procedure? Results of a one‐year randomized study. Spine 1993;18(1):24‐7. - PubMed
    1. Tullberg T, Rydberg J, Isacsson J. Radiographic changes after lumbar discectomy. Sequential enhanced computed tomography in relation to clinical observations. Spine 1993;18:843‐50. - PubMed
van Alphen 1989 {published data only}
    1. Alphen HA, Braakman R, Berfelo MW, Bezemer PD, Lostense PJ. Chemonucleolysis or discectomy? Results of a randomized multicentre trial in patients with a gerniated lumbar intervertebral disc (a preliminary report). Acta Neurochirurgica ‐ Supplementum 1988;43:35‐8. - PubMed
    1. Alphen HA, Braakman R, Bezemer PD, Broere G, Berfelo MW. Chemonucleolysis versus discectomy: a randomized multicenter trial. J Neurosurg 1989;70(6):869‐75. - PubMed
Weber 1983 {published data only}
    1. Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine 1983;8(2):131‐40. - PubMed
    1. Weber H. Lumbar disc herniation. A prospective study of prognostic factors including a controlled trial. J Oslo City Hosp 1978;28:33‐64 & 89‐120. - PubMed
Weinstein 2006 {published data only}
    1. Weinstein JN, Lurie JD, Tosteson TD, Hanscom B, Tosteson ANA, Skinner J, et al. Surgical versus non‐operative treatment for lumbar disc herniation: RCT and observational cohort outcomes from SPORT (Spine Patient Outcomes Research Trial). Proceedings of the 33rd Annual Meeting of the International Society for the Study of the Lumbar Spine, Bergen. 2006; Vol. 1:3.
    1. Weinstein JN, Tosteson TD, Lurie JD, Tosteson ANA, Hanscom B, Skinner JS, et al. Surgical vs nonoperative treatment for lumbar disk herniation. The Spine patient outcomes research trial (SPORT): a randomized trial. JAMA 2006;296(20):2451‐9. - PMC - PubMed
Yu 2001 {published data only}
    1. Yu L, Wu N, Zhang K. An investigation on the treatment of intraprotrusion or intradisk injection with collagenase for lumbar disc herniation. Chinese Journal of Clinical Rehabilitation 2002;6(4):598‐9.

References to studies excluded from this review

Burton 2000 {published data only}
    1. Burton AK, Tillotson KM, Cleary J. Single‐blind randomised controlled trial of chemonucleolysis and manipulation in the treatment of symptomatic lumbar disc herniation.. Eur Spine J 2000;9:202‐7. - PMC - PubMed
Chung 1999 {published data only}
    1. Chung J‐Y. A prospective randomized study of arthroscopic and microscopic discectomy in protruded type lumbar disc herniation.. Proceedings of ISSLS Meeting 1999, Hawaii. 1999.
Gibson 1975 {published data only}
    1. Gibson T, Dilke TFW, Grahame R. Chymoral in the treatment of lumbar disc prolapse.. Rheumatology and Rehabilitation 1975;14:186‐190.. - PubMed
Khot 2002 {published data only}
    1. Khot A, Bowditch MG, Powell JM, Sharp DJ. A prospective randomised controlled trial of intradiscal steroid injection. Proceedings of Britspine 2002. 2002.
Lee 1996 {published data only}
    1. Lee SH, Lee SJ, Park KH, Lee IM, Sung KH, Kim JS, Yoon SY. Comparison of percutaneous manual and endoscopic laser discectomy with chemonucleolysis and automated nucleotomy.. Orthopade 1996;25:49‐55. - PubMed
Livesey 2000 {published data only}
    1. Livesey JP, Sundaram S, Foster L, Peters J, Moore CA, Walker AP. Laser discectomy versus lumbar epidural steroid injection: a randomised comparative study of two treatments for sciatica. J Bone Joint Surg. 2000; Vol. 82‐B:74.
    1. Walker AP, Moore C, Sundaram S, Foster L, Livesey J. A randomised prospective study comparing laser decompression and epidural steroid injection in alleviating radicular pain secondary to prolapsed lumbar discs. Proceedings of the International Society for Study of the Lumbar Spine. 1998.
Mirzai 2006 {published data only}
    1. Mirzai H, Eminoglu M, Orguc S. Are drains useful for lumbar disc surgery? A prospective, randomized clinical study.. J Spinal Disord Tech. 2006;19(3):171‐7. - PubMed
North 1995 {published data only}
    1. North RB, Kidd DH, Piantadosi S. Spinal cord stimulation versus reoperation for failed back surgery syndrome: a prospective, randomized study design. Acta Neurochir 1995;64:106‐8. - PubMed
Ozer 2006 {published data only}
    1. Ozer AF, Oktenoglu T, Sasani M, Bozkus H, Canbulat N, Karaasrslan E, Sungurlu SF, Saruioglu AC. Preserving the ligamentum flavum in lumbar discectomy: a new technique that prevents scar tissue formation in the first 6 months postsurgery.. Neurosurgery 2006;59:126‐33. - PubMed
Petrie 1996 {published data only}
    1. Petrie JL, Ross JS. Use of ADCON‐L to inhibit postoperative peridural fibrosis and related symptoms following lumbar disc surgery: a preliminary report.. Eur Spine J 1996;5:S10‐17.. - PubMed
Reverberi 2005 {published data only}
    1. Reverberi C, Bottoli MG, Pennini M, Gabba E. Disc coblation and epidural injection of steroids: a comparison of strategies in the treatment of mechanical spinal discogenic pain.. Acta Neurochir 2005;92 [suppl]:127‐8.. - PubMed
Stula 1990 {published data only}
    1. Stula D. Chemonucleolysis with chymopapain in intervertebral disc hernia. A randomizd comparative study of patients following surgery. [Chemonukleolyse mit chymopapain bei der lumbalen diskushernie randomisierte vergleichsstudie mit operierten patienten.]. Neurochirurgia 1990;33(5):169‐72. - PubMed
Tafazal 2006 {published data only}
    1. Tafazal S, Ng L, Chaudhary N, Sell P. The efficacy of corticosteroids in peri‐radicular infiltration for radicular pain and their effect on subsequent interventions ‐ a double blinded randomised controlled trial.. Proceedings of the 33rd Annual Meeting of the International Society for the Study of the Lumbar Spine, Bergen. 2006; Vol. 1:p12.
Wittenberg 1996 {published data only}
    1. Wittenberg RH, Oppenl SC, Steffen R. Intradiscal therapy with chymopapain or collagenase: five year results of a prospective randomized investigation.. Orthop Trans. 1996‐7; Vol. 20:1064‐5.

References to ongoing studies

Akiel‐Fu 2006 {unpublished data only}
    1. Akiel‐Fu S. Study of perctaneous intradiscal nucleoplasty efficacy. NCT00189605.
Arts 2006 {published data only}
    1. Arts MP, Peul WC, Brand R, Koes BW, Thomeer RT. Cost‐effectiveness of microendoscopic discectomy versus conventional open discectomy in the treatment of lumbar disc herniation: a prospective randomised controlled trial.. BMC Musculoskeletal Disorders 2006;13:4‐42. - PMC - PubMed
Askar 2003 {published data only}
    1. Askar Z, Wardlaw D. A single blind parallel‐group study to compare low dose and standard dose chymopapain in herniated intervertebral disc disease.. Proceedings of the International Society for Study of the Lumbar Spine. 2003:238.
Katayama 2006 {published data only}
    1. Katayama Y, Matsuyama Y, Yoshihara H, Sakai Y, Nakamura H, Nakashima S, Ito Z, Ishiguro N. Comparison of surgical outcomes between macro discectomy and microdiscectomy for lumbar disc herniation: a prospective randomized study with surgery performed by the same spine surgeon.. J Spinal Disord Tech 2006;19(5):344‐7. - PubMed
Osterman 2003 {published data only}
    1. Osterman H, Seitsalo S, Malmivaara A, Karppinen J. Surgery for disc herniation. A randomized controlled trial with 2‐year follow‐up.. Proceedings of the International Society for Study of the Lumbar Spine. 2003:P20. - PubMed
    1. Osterman H, Seitsalo S, Malmivaara A. Six‐year otcomes of lumbar microdiscectomy. Results of a randomised controlled trial.. Proceedings of the International Society for the Study of the Lumbar Spine.. 2005:18.
Peul 2006 {unpublished data only}
    1. Peul WC. Microendoscopic discectomy (MED) is more (cost)‐effective than open discectomy. ISRCTN51857546.
Rowe , 2004 {published data only}
    1. Rowe SM, Moon E‐S, Song EK, Lee KB, Seo HY, Chung JY. A prospective randomized study of percutaneous endoscopic and microscopic lumbar discectomy. Proceedings of the American Academy of Orthopaedic Surgeons. 2004:Poster P397.
Schenk 2006 {unpublished data only}
    1. Schenk B. Percutaneous laser disc decompression is more cost‐effective than conventional surgical treatment for lumbar disc herniation and allows faster patient rehabilitation, while long‐term results are comparable.. ISRCTNR25884790.
Terheggen 2006 {unpublished data only}
    1. Terheggen M. Nucleoplasty for contained herniated lumbar discs. NCT00124774.

Additional references

Bessette 1996
    1. Bessette L, Liang MH, Lew RA, Weinstein JN. Classics in spine surgery revisited. Spine 1996;21:259‐63. - PubMed
Bouillet 1987
    1. Bouillet R. Complications de la nucleolyse discale par la chymopapaine. Acta Orthop Belg 1987;53:250‐60. - PubMed
Carlisle 2005
    1. Carlisle E, Luna M, Stou PM, Wang JC. Percent spinal canal compromise on MRI utilized for predicting the need for surgical treatment in single‐level lumbar intervertebral disc herniation. Spine Journal 2005;5:608‐14. - PubMed
Carragee 2003
    1. Carragee EJ, Han MY, Suen PW, Kim D. Clinical outcomes after lumbar discectomy for sciatica: the effects of fragment type and anular competence. J Bone Joint Surg 2003;85‐A(1):102‐8. - PubMed
Deyo 1998
    1. Deyo RA, Battie M, Beurskens AJHM, et al. Outcome measures for low back pain research: a proposal for standardized use. Spine 1998;23:2003‐13. - PubMed
Goosens 1998
    1. Goosens M, Evers S. Economic evaluation of back pain interventions. In: Nachemson A, Jonsson E. (eds). SBU report on back pain.. Stockholm: Swedish Council on Technology Assessment in Health Care, 1998:Swedish Council on Technology Assessment in Health Care. In press, 1998.
Higgins 2005
    1. Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions 4.2.4 (updated March 2005). www.cochrane.org/resources/handbook/hbook.htm. accessed 31 March 2005.
Hoffman 1993
    1. Hoffman RM, Wheeler KJ, Deyo RA. Surgery for herniated lumbar discs: a literature synthesis. J Gen Int Med 1993;8:487‐96. - PubMed
Kahanovich 1995
    1. Kahanovich N, Viola K, McCulloch JA. Limited surgical discectomy and microdiscectomy: a clinical comparison. Spine 1989;14:79‐81. - PubMed
Kambin 2003
    1. Kambin P, Vaccaro A. Arthroscopic microdiscectomy. The Spine Journal 2003;3 (Suppl.1)(3):60‐64. - PubMed
Malter 1996
    1. Malter AD, Larson EB, Urban N, Deyo RA. Cost‐effectiveness of lumbar discectomy for the treatment of herniated intervertebral disc. Spine 1996;21:1048‐55. - PubMed
Onik 1990
    1. Onik G, Mooney V, Maroon JC, et al. Automated percutaneous discectomy: a prospective multi‐institutional study. Neurosurgery 1990;2:228‐33. - PubMed
Scheer 1996
    1. Scheer SJ, Radack KL, O'Brien DR. Randomised controlled trials in industrial low back pain relating to return to work. Part 2. Discogenic low back pain. Arch Phys Med Rehabil 1996;77:1189‐97. - PubMed
Schulz 1995
    1. Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of bias dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 1995;273:408‐12. - PubMed
Smith 1964
    1. Smith L. Enzyme dissolution of nucleus pulposus in humans. JAMA 1964;187:137‐40. - PubMed
Stevens 1997
    1. Stevens CD, Dubois RW, Larequi‐Lauber T, Vader J‐P. Efficacy of lumbar discectomy and percutaneous treatments for lumbar disc herniation. Soz‐Pravedtivmed 1997;42:367‐79. - PubMed
Taylor 1989
    1. Taylor ME. Return to work following back surgery: A review. Amer J Ind Med 1989;16:79‐88. - PubMed

References to other published versions of this review

Gibson 1999
    1. Gibson JNA, Grant IC, Waddell G. The Cochrane review of surgery for lumbar disc prolapse and degenerative lumbar spondylosis. Spine 1999;24(17):1820‐32. - PubMed
Gibson 1999a
    1. Gibson JNA, Grant IC, Waddell G. Surgery for lumbar disc prolapse. Cochrane Database of Systematic Reviews 1999, Issue 1. [DOI: 10.1002/14651858.CD001350.pub4] - DOI - PubMed
Gibson 2000
    1. Gibson JNA, Grant IC, Waddell G. Surgery for lumbar disc prolapse. Cochrane Database of Systematic Reviews 2000, Issue 3. [DOI: 10.1002/14651858.CD001350.pub4] - DOI - PubMed
Gibson 2007
    1. Gibson JNA, Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database of Systematic Reviews 2007, Issue 1. [DOI: 10.1002/14651858.CD001350.pub4] - DOI - PubMed

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