A Systematic Review of Treatment Guidelines for Lumbar Disc Herniation

Abstract

Various treatments have been developed for treating herniated lumbar discs (HLD), which have been examined by professional associations when composing clinical guidelines that provide structured approaches to treating HLD. This paper aims to gather recent guidelines and summarize their conclusions on nonsurgical and surgical treatment options. PubMed, Web of Science, Scopus, Guidelines International Network, Turning Research into Practice databases, and websites of medical societies were searched for clinical guidelines of HLD. Full-text guidelines published by a professional association in English relevant to HLD were included. Comparisons among guidelines were made based on the treatments evaluated, and recommendation grades were recorded when provided by the guidelines. A total of 12 guidelines were included, with 4 by non-United States (US) or international associations, 3 by US pain societies, 2 by surgical societies, 2 by government agencies, and 1 by a multidisciplinary medical society. Treatments assessed included surgical, invasive nonsurgical, and noninvasive nonsurgical interventions. Three guidelines did not include surgical treatments, and 2 guidelines did not include nonsurgical therapies. Recommendation criteria varied among guidelines due to differences in the intended audience. HLD can be treated with various modalities with specific therapies offering better pain relief. Despite inconsistency in the recommendation grades of most treatments, established surgical techniques and epidural injections were reported with higher confidence in recommendation estimates, while inadequate supporting evidence was shown for noninvasive therapies except cognitive behavioral therapy. Future studies could incorporate and comment on some of the newer methods of treating HLD.

Keywords: Herniated disc; Low back pain; Pain.

Fig. 1.

PRISMA (Preferred Reporting Items for Systematic Review Meta-analyses) diagram detailing the literature review process. HLD, herniated lumbar disc.

Fig. 2.

Quantified summary of noninvasive treatment recommendations. TENS, transcutaneous electrical nerve stimulation; CBT, cognitive behavioral therapy; NSAIDs, nonsteroidal anti-inflammatory drugs.

Fig. 3.

Quantified summary of invasive nonsurgical treatment recommendations. PNS, peripheral nerve stimulation; RFA, radiofrequency ablation; TFESI, transforaminal epidural steroid injections; ESI, epidural steroid injections; IA LFJ, intraarticular lumbar facet joint.

Fig. 4.

Quantified summary of surgical treatment recommendations. IDET, intradiscal electrothermal annuloplasty; PED, percutaneous endoscopic discectomy; HLD, herniated lumbar disc; MD, microdiscectomy; MED, microendoscopic discectomy; OD, open discectomy; TD, tubular discectomy; SCS, spinal cord stimulation; PNFS, peripheral nerve field stimulation; PA, percutaneous adhesiolysis.