Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Nonoperative care versus surgery in lumbar disc herniation with radiculopathy. what is the evidence?

1,712 views

Published on

This is a brief review of the current state of evidence for nonoperative versus operative care for lumbar disc herniation with radiculopathy. The current NASS guidelines are summarized.

Published in: Health & Medicine
  • Be the first to comment

Nonoperative care versus surgery in lumbar disc herniation with radiculopathy. what is the evidence?

  1. 1. Dr. Kshitij Chaudhary, MS, DNB Consultant Spine Surgeon Sir HN Reliance Foundation Hospital, Mumbai N O N O P E R A T I V E V E R S U S S U R G I C A L M A N A G E M E N T L U M B A R D I S C H E R N I A T I O N W H A T I S T H E E V I D E N C E ?
  2. 2. Levels of Evidence Level 1 High quality RCT Level 2 Prospective comparative Low quality RCT Level 3 Retrospective comparative Level 4 Case series Level 5 Expert opinion
  3. 3. The Evidence RCTs 5 Prospective comparative 4 Retrospective comparative 1 Surgery versus Nonop treatment
  4. 4. RCT 126 patients Discectomy or Physical therapy Outcome measures - Unvalidated measure (Poor, Fair, Good, Ex) 10 year FU 1 year - Surgery better 4 year - Surgery equivalent to PT
  5. 5. RCT 100 patients failed noninvasive therapy for 6 weeks Discectomy or ESI Outcome measures - ODI, VAS, Pt satisfaction 2-3 years FU Discectomy did better (short term) No statistical advantage for surgery at the end Buttermann et al, JBJS Am 2004
  6. 6. RCT 56 patients with radicular pain for 6-8 wks Discectomy or Physical therapy Outcome measures - ODI and VAS 2 years FU Discectomy short term benefit At 2 years → no difference
  7. 7. RCT 208 patients Discectomy or Nonoperative Rx Outcome measures - ODI and VAS 2 years FU Discectomy better at 6 months At 1 and 2 years → no difference Puel et al, BMJ 2008
  8. 8. RCT (multicenter) 501 patients Discectomy (245) or Nonoperative Rx (256) Outcome measures - SF36, ODI, Self reported outcome, work status and satisfaction 2 and 4 years FU No clinically or statistically significant difference between discectomy and non-operative treatment.
  9. 9. f multiple RCTs over last 2 decades are showing no difference Then why do discectomy at all ?
  10. 10. Patients with radiculopathy (100) Surgery (50) Conservative Rx (50)Randomized Ideally, at End of Study
  11. 11. Patients with radiculopathy (100) Surgery (30) Conservative Rx (30)Randomized In real life Intent to Treat Cross over
  12. 12. At best these RCT studies are Level 2
  13. 13. Prospective cohort Level 2 Summary Follow up Spengler et. al. 77% good result with surgery Minimum 1 year Atlas et. al. (MAINE STUDY) Surgical group did better up to 10 years 1, 5 and 10 years Weinstein et. al. (SPORT) Significantly better outcomes for surgery at 3mo, 1, 2 and 4 years 2 and 4 years Guilfoyle et. al. Significant improvement in SF-36 and RM scores at 2 years 2 years
  14. 14. Retrospective cohort study Out of 58 patient in conservative group 90% had good results However, 347 patients were enrolled and only 58 were followed What happened to the remaining 289 patients? Saal and Saal, Spine 1989
  15. 15. Current Recommendation Discectomy is suggested to provide more effective symptom relief than medical/interventional care for patients with lumbar disc herniation with radiculopathy whose symptoms warrant surgical intervention. In patients with less severe symptoms, surgery or medical/interventional care appear to be effective for both short- and long-term relief. NASS Guidelines 2014 Grade of Recommendation: B
  16. 16. What about patients with motor deficit ? Is surgery better ?
  17. 17. Neurological deficit Complete motor recovery Weber (1983) 96% non operative cohort 94% operative cohort Hekelius (1970) 77% non operative cohort 76% operative cohort Can you really apply this to severe deficits?
  18. 18. Natural history severe deficits MRC<3 Buttermann (2004) 100% recovery with surgery 0% with nonoperative treatment Dubourg (2002) 25% recovery with surgery 32% with nonoperative treatment 0 - 32% recovery for severe deficits
  19. 19. Systematic Review 7 studies with 354 patients Grade 3 or worse Surgery - 38% recovery (at least MRC 4 in 52%) Nonoperative treatment - 32% recovery Timing - inconclusive Only 6% difference
  20. 20. Guidelines
  21. 21. Grades of Recommendation Grade A 2 or more consistent Level 1 studies Grade B Two or more consistent Level 2 or 3 studies Grade C Two or more consistent Level 4 studies Grade I Single study or multiple studies with inconsistent findings
  22. 22. Pharmacological treatment Grade I Insufficient evidence (Gabapentin, Steroids, Amytriptyline, NSAIDS) Physical therapy Grade I Expert consensus - limited course of structured exercise for mild to moderate symptoms Traction Grade I Insufficient evidence for or against
  23. 23. TFESI (short term) Grade A TFESI provide short term pain relief (2-4 weeks) TFESI (long term) Insufficient evidence Insufficient evidence for or against 12 month efficacy of TFESI Interlaminar ESI Grade C Interlaminar ESI may be considered
  24. 24. Nucleoplasty Grade I Insufficient evidence for or against Plasma disc decompression Grade I Insufficient evidence for or against Percutaneous Electrothermal disc decompression Grade I Insufficient evidence for or against
  25. 25. Intradiscal Ozone Grade I Insufficient evidence for or against Automated percutanous discectomy (versus open discectomy) Grade I Insufficient evidence for or against Endoscopic percutaneous discectomy (versus open discectomy) Grade B Endoscopic discectomy suggested in carefully selected patients (lesser early post pain compared to open)
  26. 26. Thank you www.spinemumbai.in Twitter @kcspine kshitijchaudhary.wordpress.com

×