Conservative Versus Aggressive Disc Removal: What Do the Experts Have to Say?If you have back and leg pain from a herniated disc, is it better to have surgery that takes the whole disc out (aggressive discectomy) or are the results just as good with a conservative approach (take out only the disc fragment)? That's the topic of this study.
The authors reviewed all of the published data from the last 40 years. This type of study is called a systematic review. They only included studies that directly compared these two open-incision discectomy techniques.
Patients all had low back and leg pain. The leg pain is referred to as radiculopathy. A more common name is sciatica. It is caused by pressure on the spinal nerve root or chemical irritation of the nerve root from the herniated disc or disc fragments. Studies using more recently developed minimally invasive approaches were not included.
They tried to answer four questions. 1) Which has better short-term (up to 28 days) results: aggressive or conservative discectomy? 2) Which has better medium-length results (up to two years after the surgery)? 3) How do the results compare after two years? 4) Which one has a higher rate of a second (recurrent) disc herniation?
As a surgeon (or patient) trying to decide which surgical approach is best, the answers to these four questions could be very helpful. After conducting the search, the authors summarized each study in a table. The name of the article, authors' names, and publication citation were provided for 25 publications.
There were initially 621 studies that had some reference to open surgical treatment for disc herniation. But after reviewing them more carefully, only the 25 chosen directly compared aggressive versus conservative discectomy or reported the results of one of these approaches.
Level of evidence (from one to five/high-to-low quality), brief description of the study, and conclusions were presented. Strengths and weaknesses and critiques of the article were incorporated in the table. Most of the articles were really a level IV evidence, which means they were case studies, not randomized controlled (high-quality) studies. In fact, only one study was at the level II evidence and none were the highest quality (level I).
Just finding out that the level of evidence comparing these two studies is so limited was a valuable result of this study. It helped point out the need to design and carry out randomized trials. High-quality trials are needed to really get a handle on how the results of these two procedures compare.
What can be said is that there isn't any good evidence to say that an aggressive approach is better than a more conservative one. Only taking out disc fragments (rather than removing the entire disc) takes less time in the operating room and gets people back to work faster than the more aggressive removal of the entire disc.
Taking a closer look at medium- and long-term results showed that there was no advantage to the more aggressive approach. Patients in both groups had equal improvement in function and the same incidence of recurrence early on. Recurrence refers to cases where the same disc herniated again. There was some indication that the further out the patient was from the surgery, the more likely a reherniation might occur with the conservative approach.
Any further conclusions just can't be made from the data collected so far. And it should be kept in mind that these conclusions were made from the currently available low-level quality of evidence. Choosing the conservative approach follows the guidelines for best practice based on what evidence there is, but this choice comes with the potential risk of reherniation requiring additional surgery.
William C. Watters, III, MD, and Matthew J. McGirt, MD. An Evidence-Based Review of the Literature on the Consequences of Conservative Versus Aggressive Discectomy for the Treatment of Primary Disc Herniation with Radiculopathy. In The Spine Journal. March 2009. Vol. 9. No. 3. Pp. 240-257.
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