• increased intracranial pressure (ICP);• normal/small ventricles on neuro-imaging;• no evidence of intracranial mass;• normal CSF composition (a low CSF protein is acceptable).
EBS PresentationIndications and timing of surgery for lumbardisc herniation Johnny Wong 20th October, 2011 Advanced Scholar: Dr Kevin Seex
Clinical Case & Question• 40 year old man presented with: – Severe sciatic pain – 2 – 3 weeks duration – Unable to be controlled with analgesia.• What are the indications and appropriate timing for discectomy for acute lumbar disc prolapse?
Search strategy• P = Patients with sciatica due to lumbar disc herniation• I = Microdiscectomy (+/- fusion) within 2 – 3 weeks• C = Conservative treatment or late surgery• O = Treatment outcomes – pain, disability scores, neuro deficits, Indications• Cochrane, Ovid Medline, Scopus, Google Scholar
Search terms• P = “Disc herniation” – MeSH: Intervertebral disk degeneration – Keywords: “disc prolapse”, “disc herniation”• I = “Microdiscectomy” – MeSH: Diskectomy – Keywords: “diskectomy”; “microdiskectomy”• I = “Early surgery” – MeSH: Time factors – Keywords: “Timing adj3 surgery”, “early surgery”
• Update of previous Cochrane review • Objectives: Cochrane – 6 different objectives, including: • Microdiscectomy vs conservative • Microdiscectomy vs MIS • Microdiscectomy vs chemonucleolysis • Methods: – RCT and quasi RCT from 2003 – 2007 – Sciatica & radiology lumbar disc (<6wk - > 6mo) • Results: – 40 RCTs, 2 qRCTs. – Too few studies had information on duration of symptoms pre-op – 3 studies: Discectomy vs ConvservativeOptimal timing not investigated • Discussion (on discectomy) : – Prolonging surgery may delay recovery but does not produce long-term harm – Primary indication – Rapid relief of pain
Ovid Medline 6 Useful articles: Early Surgery vs Conservative Looked up complete references: Another 2 articles found
Scopus & Google scholar• Scopus: – Searched from reference list from medline useful articles – 3 more useful articles• Google scholar – Nil further useful articles
• 5 RCTs of adults with lumbar herniated discs causing radicular pain to Oct 2009; Symptoms for 6-12 weeks before randomisation• Early surgery vs conservative (1 RCT: option of surgery; 3 RCT prolonged conservative; 1 RCT epidural injection)• Results not be pooled - heterogeneity• Significantly more relief of leg pain at 3 & 6 months with surgery. No difference in pain or disability scores > 12 months
• Retrospective series of 46 patients• Surgery: Early (<3 months of sciatica) vs Late (> 3 months)• Mean duration of symptoms: 1.8 months vs 7.2 months• No signficant differences in VAS or disability scores
• RCT: 283 patients (141 surgery vs 142 conservative); 9 centres• Symptoms for 6 – 12 weeks; surgery within 2 weeks of randomisation; 85% open microdiscectomy
• Same study group as Peul et al.• To determine whether baseline variables can predict response to treatment for surgery• Identify effect modifiers for surgery• Only predictive factor is sciatica provoked by sitting (p = 0.07) – Improved with surgery
• Retrospective review of natural history with max conservative management, analysed according to contained vs non-contained discs• Conservative treatment for non-contained discs may avoid surgery• No difference with contained discs• “Contained discs should be operated upon within 1 month”
• 501 patients eligible; symptoms for > 6 weeks• Multi-centre RCT• Significant non-compliance (50% received surgery within 3 months in surgical arm, 30% conservative received surgery)• Loss to follow-up at 2 years: 75% had data available• Intention to treat analysis• No significant difference in VAS or ODI scores at 2 years
• As treated analyses at 4 years:• Significant differences in disability and SF-36• Non-significance if intention to treat.
Conclusion• No studies on surgery within 4 weeks of symptoms• “Early surgery” – earlier relief of sciatica, but no better in long-term outcome when compared with conservative treatment