Surgical vs Nonoperative Treatment for Lumbar Disk Herniation

Weinstein, James Neil; Tosteson, Tor D.; Lurie, Jon D.; Tosteson, Anna N.A.; Hanscom, Brett; Skinner, Jonathan; Abdu, William A.; Hilibrand, Alan S.; Boden, Scott D.; Deyo, Richard A.

doi:10.1001/jama.296.20.2441

Cited by 955 publications

(343 citation statements)

References 27 publications

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“…We had to register 5% which is marginally higher than the figures reported in the literature's greatest patient cohort by Oppel et al [27,37] of 3.7% and for the SPORT study. As looking at a minimal invasive procedure with a potentially higher risk of dural lesions we did not find any differences between the procedures.…”

Section: Discussionmentioning

confidence: 62%

Comparison of a minimally invasive procedure versus standard microscopic discotomy: a prospective randomised controlled clinical trial

Franke

Greiner-Perth²,

Boehm

et al. 2009

Eur Spine J

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A Prospective randomised controlled study was done to determine statistical difference between the standard microsurgical discotomy (MC) and a minimally invasive microscopic procedure for disc prolapse surgery by comparing operation duration and clinical outcome. Additionally, the transferability of the results was determined by a bicentric design. The microscopic assisted percutaneous nucleotomy (MAPN) has been advocated as a minimally invasive tubular technique. Proponents have claimed that minimally invasive procedures reduce postoperative pain and accelerate the recovery. In addition, there exist only a limited number of well-designed comparison studies comparing standard microdiscotomy to a tubular minimally invasive technique that support this claim. Furthermore, there are no well-designed studies looking at the transferability of those results and possible learning curve phenomena. We studied 100 patients, who were planned for disc prolapse surgery at two centres [50 patients at the developing centre (index) and 50 patients at the less experienced (transfer) centre]. The randomisation was done separately for each centre, employing a blockrandomisation procedure with respect to age and preoperative Oswestry score. Operation duration was chosen as a primary outcome parameter as there was a distinguished shortening observed in a preliminary study at the index centre enabling a sound case number estimation. The following data were compared between the two groups and the centres with a 12-month follow-up: surgical times (operation duration and approach duration), the clinical results, leg and back pain by visual analogue scale, the Oswestry disability index, length of hospital stay, return to work time, and complications. The operation duration was statistically identical for MC (57.8 ± 20.2 min) at the index centre and for MAPN (50.3 ± 18.3 min) and MC (54.7 ± 18.1 min) at the transfer centre. The operation duration was only significantly shorter for the MAPN technique at the index centre with 33.3 min (SD 12.1 min). There was a huge clinical improvement for all patients regardless of centre or method revealed by a repeated measures ANOVA for all follow-up visits Separate post hoc ANOVAs for each centre revealed that there was a significant time-method (MAPN vs. MC) interaction at the index centre (F = 3.75, P = 0.006), whereas this crucial interaction was not present at the transfer centre (F = 0.5, P = 0.7). These results suggest a slightly faster clinical recovery for the MAPN patients only at the index centre. This was due to a greater reduction in VAS score for back pain at discharge, 8-week and 6-month follow up (P \ 0.002). The Oswestry-disability scores reached a significant improvement compared to the initial values extending over the complete follow-up at both centres for J. Franke and R. Greiner-Perth contributed equally to this work. both methods without revealing any differences for the two methods in either centre. There was no difference regarding complications. The results demonstrate...

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Section: Discussionmentioning

confidence: 62%

Comparison of a minimally invasive procedure versus standard microscopic discotomy: a prospective randomised controlled clinical trial

Franke

Greiner-Perth²,

Boehm

et al. 2009

Eur Spine J

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“…First, our cohort was a sample of patients referred to the participating clinics and did not include all sciatica patients in need of secondary care in the target population. However, our patients closely resembled the Maine [3] and SPORT [40] studies with regard to demographic and clinical characteristics, but had somewhat less severe symptoms than in the randomized study by Peul et al [27]. Second, because clinical tests were rated as normal or abnormal only, we were unable to fully assess whether patients with higher self-reported ratings of bothersomeness actually had more serious clinical findings.…”

Section: Discussionmentioning

confidence: 65%

“…A composite score can be calculated by summing up the ratings across the four symptom scales. The SBI has been used in several studies [3,27,40], and three of the items have been incorporated in the North American Spine Society outcome instrument [8]. To date, results generated from the SBI have only been published as composite scores, resulting in a dearth of data for individual items such as numbness/tingling (paresthesia) and weakness.…”

Section: Introductionmentioning

confidence: 99%

The bothersomeness of sciatica: patients’ self-report of paresthesia, weakness and leg pain

et al. 2009

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The objective of the study was to investigate how patients with sciatica due to disc herniation rate the bothersomeness of paresthesia and weakness as compared to leg pain, and how these symptoms are associated with socio-demographic and clinical characteristics. A crosssectional study was conducted on 411 patients with clinical signs of radiculopathy. Items from the Sciatica Bothersomeness Index (0 = none to 6 = extremely) were used to establish values for paresthesia, weakness and leg pain. Associations with socio-demographic and clinical variables were analyzed by multiple linear regression. Mean scores (SD) were 4.5 (1.5) for leg pain, 3.4 (1.8) for paresthesia and 2.6 (2.0) for weakness. Women reported higher levels of bothersomeness for all three symptoms with mean scores approximately 10% higher than men. In the multivariate models, more severe symptoms were associated with lower physical function and higher emotional distress. Muscular paresis explained 19% of the variability in self-reported weakness, sensory findings explained 10% of the variability in paresthesia, and straight leg raising test explained 9% of the variability in leg pain. In addition to leg pain, paresthesia and weakness should be assessed when measuring symptom severity in sciatica.

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“…After imaging, L5-S1 bone-disc-bone segments were separated from the spine and prepared for testing. The L5-S1 disc was selected because herniation, and subsequent surgery, is most common at this level [34]. The samples for this study had degeneration grades ranging from 1 to 5 and T 2 relaxation times ranging from 79 to 204, with higher relaxation times indicating healthier discs.…”

Section: Methodsmentioning

confidence: 99%

Evaluation of an In Situ Gelable and Injectable Hydrogel Treatment to Preserve Human Disc Mechanical Function Undergoing Physiologic Cyclic Loading Followed by Hydrated Recovery

Showalter

Elliott

Chen

et al. 2015

Journal of Biomechanical Engineering

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Despite the prevalence of disc degeneration and its contributions to low back problems, many current treatments are palliative only and ultimately fail. To address this, nucleus pulposus replacements are under development. Previous work on an injectable hydrogel nucleus pulposus replacement composed of n-carboxyethyl chitosan, oxidized dextran, and teleostean has shown that it has properties similar to native nucleus pulposus, can restore compressive range of motion in ovine discs, is biocompatible, and promotes cell proliferation. The objective of this study was to determine if the hydrogel implant will be contained and if it will restore mechanics in human discs undergoing physiologic cyclic compressive loading. Fourteen human lumbar spine segments were tested using physiologic cyclic compressive loading while intact, following nucleotomy, and again following treatment of injecting either phosphate buffered saline (PBS) (sham, n ¼ 7) or hydrogel (implant, n ¼ 7). In each compressive test, mechanical parameters were measured immediately before and after 10,000 cycles of compressive loading and following a period of hydrated recovery. The hydrogel implant was not ejected from the disc during 10,000 cycles of physiological compression testing and appeared undamaged when discs were bisected following all mechanical tests. For sham samples, creep during cyclic loading increased (þ15%) from creep during nucleotomy testing, while for implant samples creep strain decreased (À3%) toward normal. There was no difference in compressive modulus or compressive strains between implant and sham samples. These findings demonstrate that the implant interdigitates with the nucleus pulposus, preventing its expulsion during 10,000 cycles of compressive loading and preserves disc creep within human L5-S1 discs. This and previous studies provide a solid foundation for continuing to evaluate the efficacy of the hydrogel implant.

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Surgical vs Nonoperative Treatment for Lumbar Disk Herniation

Abstract: clinicaltrials.gov Identifier: NCT00000410.

Cited by 955 publications

References 27 publications

Comparison of a minimally invasive procedure versus standard microscopic discotomy: a prospective randomised controlled clinical trial

Comparison of a minimally invasive procedure versus standard microscopic discotomy: a prospective randomised controlled clinical trial

The bothersomeness of sciatica: patients’ self-report of paresthesia, weakness and leg pain

Evaluation of an In Situ Gelable and Injectable Hydrogel Treatment to Preserve Human Disc Mechanical Function Undergoing Physiologic Cyclic Loading Followed by Hydrated Recovery

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