| Lilly et al.55 Lilly DT, Davison MA, Eldridge CM, Singh R, Montgomery EY, Bagley C, et al. An assessment of nonoperative management strategies in a herniated lumbar disc population: successes versus failures. Global Spine J. 2021;11(7):1054-63.
|
Retrospective cohort |
NSAIDs; opioids, muscle relaxants, steroid injections, physical therapy and occupational therapy sessions, and chiropractic treatment. |
Microdiscectomy |
Of a total of 277941 patients evaluated in the study, 97% were successful with conservative treatment and only 3% were submitted to surgery. |
| Gugliotta et al.99 Gugliotta M, da Costa BR, Dabis E, Theiler R, Jüni P, Reichenbach S, et al. Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study. BMJ Open. 2016;6(12):e012938.
|
Prospective cohort study |
Ergonomic instruction, active physical therapy, counseling with instructions for home exercises, NSAIDs, opioids, epidural opioid infiltrations, and CT-guided pulsed radiofrequency of the affected nerve root. |
Standard open discectomy |
370 patients participated in the study, 297 received surgical treatment, 73 received conservative treatment. Patients submitted to surgical treatment reported less back pain at 6 weeks than those of conservative therapy. However, this difference decreased over time and after 12 weeks no relevant clinical difference was observed. |
| Koksal and Koc1515 Koksal V, Koc RK. Microsurgery versus medical treatment for neuropathic pain caused by foraminal or extraforaminal lumbar disc herniation: an observational study. Turkish Neurosurg. 2019;29(6):915-26.
|
Prospective case control |
NSAIDs; corticosteroids; analgesics; opioids; gabapentin; pregabalin and intravenous steroids. |
Intertransverse transmuscular microsurgery |
83 patients were monitored, 37 of whom underwent surgery and 46 underwent conservative treatment. If surgical treatment for foraminal / extraforaminal low back disc herniation is delayed, the risk of persistent neuropathic pain (NP) may increase. NP can be prevented by sufficient decompression of the dorsal root ganglion. |
| Arts et al.1212 Arts M P, Kuršumović A, Miller LE, Wolfs JFC, Perrin JM, Van de Kelft E, et al. Comparison of treatments for lumbar disc herniation: Systematic review with network meta-analysis. Medicine. 2019;98(7):e14410.
|
Systematic review and meta-analysis |
Non-surgical multimodal treatments, physical therapy, spinal manipulation, and epidural steroid injections. |
Low back discectomy with bone anchored annular closure and low back discectomy |
Surgical treatment (low back discectomy and low back discectomy with bone anchored annular closure) is more effective than continuous conservative treatment for low back disc herniation. Low back discectomy with bone anchored annular closure > low back discectomy > conservative treatment. Surgical treatment was more effective in reducing leg pain, back pain and disability (herniated disc symptoms). |
| Bailey et al.1111 Bailey CS, Rasoulinejad P, Taylor D, Sequeira K, Miller T, Watson J, et al. Surgery versus conservative care for persistent sciatica lasting 4 to 12 months. N Engl J Med. 2020;382(12):1093-102.
|
Prospective cohort |
Patient education, activities and exercises, use of oral analgesics and active physical therapy, as well as epidural injection of glucocorticoids. |
Microdiscectomy |
Out of a total of 128 patients, 64 underwent conservative treatment and 64 surgical treatments. At the beginning of the study, the leg pain intensity score was 7.7 in the surgery group and 8 in the non- surgery group. At 6 months, the score for pain intensity was 2.8 in the surgery group and 5.2 in the non-surgery group |
| Delgado-López et al.11 Delgado-López PD, Rodríguez-Salazar A, Martín-Alonso J, Martín-Velasco V. Lumbar disc herniation: natural history, role of physical examination, timing of surgery, treatment options and conflicts of interests. Neurocirugía. 2017;28(3):124-34.
|
Literature review |
|
|
The recommended initial treatment is generally conservative since a high percentage of patients recover or experience gradual and substantial pain improvement within 4-6 weeks. Both people who undergo surgery and those who are not submitted to it experience similar levels of pain after one year. |
| Chen et al.1010 Chen BL, Guo JB, Zhang HW, Zhang YJ, Zhu Y, Zhang J, et al. Surgical versus non-operative treatment for lumbar disc herniation: a systematic review and meta-analysis. Clin Rehabil. 2018;32(2):146-60.
|
Systematic review with systematic reviews and meta-analyses of randomized clinical trials |
Physical therapy, pharmacological therapy, and rest |
|
Clinical data suggest that surgery is more effective in improving physical function and quality of life than non-operative treatment.
For patients with low back disc herniation, there is evidence that surgical treatment is more effective than conservative treatments in reducing short- and medium-term pain, short-term quality of life, and medium- and long-term disability.
|
| Altun and Yüksel 66 Altun I, Yüksel KZ. Lumbar herniated disc: spontaneous regression. Korean J Pain. 2017;30(1):44-50.
|
Retrospective cohort |
NSAIDs, muscle relaxants and opioids |
Discectomy |
23 patients were monitored in this cohort study and all presented improvement with conservative treatment over a 13.6 month period.
The surgical approach provides faster symptomatic relief compared to conservative treatment. However, the results are similar for conservative and surgical treatment after 2 years.
|
| Furunes et al.1414 Furunes H, Hellum C, Espeland A, Brox JI, Småstuen MC, Berg L, et al. Adjacent disc degeneration after lumbar total disc replacement or nonoperative treatment: a randomized study with 8-year follow-up. Spine. 2018;43(24):1695-703.
|
Randomized case-control study |
A modern multidisciplinary rehabilitation with cognitive approach and supervised exercise for three to five weeks. |
Total low back disc replacement (TDR) |
Adjacent disc degeneration increased in 40% of patients treated non-surgically and in 42% of patients treated surgically (p=0.86). |
| Sussela et al.77 Sussela AO, Bittencourt AB, Raymondi KG, Tergolina SB, Ziegler MS. Hérnia de disco: epidemiologia, fisiopatologia, diagnóstico e tratamento. Acta Méd. 2017;38(7):34-44.
|
Literature review |
|
|
The first choice for symptomatic herniated disc scenarios are the non-surgical options, in view of the generally benign natural history of this disease, since in 60-90% of cases spontaneous resolution of symptoms occurs within the first 6-12 weeks. Absolute indications for surgical treatment are cauda equina syndrome or significant paresis. Relative indications are sciatic pain that has not responded to conservative treatment for at least six weeks and motor deficit greater than grade 3, or radicular pain associated with foraminal bone stenosis. |
| Clark, Weber and Kahwati88 Clark R, Weber RP, Kahwati L. Surgical management of lumbar radiculopathy: a systematic review. J Gen Intern Med. 2020;35(3):855-64.
|
Systematic review |
Physical therapy, pharmacological treatment, spinal manipulation, chiropractic treatment or a combination of these. |
Discectomy, laminectomy, laminotomy, foraminotomy, nucleotomy, and nucleoplasty including micro- and minimally invasive approaches. |
Surgery reduced leg pain by 6-20 points on a zero to 100 point pain scale at up to 26 weeks of follow-up. Differences between groups did not persist at 1 year or later. Minimal differences were observed at 2 years. Compared with nonsurgical interventions, surgery probably reduces pain and improves function in the short to medium term, but the difference does not persist in the medium to long term. |
| Garcia-Saiz et al.1313 Garcia-Saiz I, San Norberto EM, Tamayo E, Ortega E, Aldecoa C. Quantitative sensory testing to evaluate and compare the results after epidural injection and simple discectomy, in patients with radiculopathy secondary to lumbar disc herniation. J Clin Monit Comput. 2020;34(5):1095-104.
|
Prospective cohort |
Epidural injection |
Simple discectomy |
74 patients participated in the study: 50 underwent conservative treatment and 24 surgical treatments. After one month of follow-up, the patients submitted to surgery had better results on the QST than the patients submitted to steroid injection, this difference disappeared after 6 months of follow-up, when no statistically significant differences were found in any parameter measured by the QST. |
| Abou-Elroos et al.2020 Abou-Elroos DA, El-Toukhy MAE-H, Nageeb GS, Dawood EA, Abouhashem S. Prolonged physiotherapy versus early surgical intervention in patients with lumbar disk herniation: short-term outcomes of clinical randomized trial. Asian Spine J. 2017;11(4):531-7.
|
Randomized controlled trial |
Physical therapy and rehabilitation (modification of activities); soft tissue massage; electrotherapy; static exercises for abdominal muscles, back muscles, and hip extensors; stretching exercises for the hamstrings, as well as range of motion (ROM) exercises; and pharmacological treatment with muscle relaxants, analgesics, anti-inflammatory drugs, pregabalin, and vitamin B complex. |
Surgical discectomy |
An extended physical therapy and rehabilitation program is beneficial and successful in patients with a recent diagnosis of low back disc herniation. This program can better improve functional capacity and facilitate the return to work compared to early surgical intervention. Other studies have reported that patients with low back disc prolapse who were treated surgically had better physical function and ability to work than those who were treated conservatively after 3 months; however, this difference was decreasing at the 2 years follow-up. |
| Petersen, Juhl and Fournier1717 Petersen T, Juhl CB, Fournier GL. Patients with persistent low back pain and nerve root involvement: to operate, or not to operate, that is the question. Spine. 2020;45(7):483-90.
|
Prospective cohort |
Multidisciplinary team with rheumatologists, physical therapists, chiropractors, and a social worker. Treatment included a thorough examination, biopsychosocial approach on patient concerns, education on activities of daily living, individually adapted exercises, and manual therapy based on physical examination findings. |
Not specified. |
Approximately 30% of patients with low back disc herniation or low back spinal stenosis were unsuccessful at 2-year follow-up when they underwent surgery after unsuccessful conservative treatment. Surgical treatment was associated with better outcomes than cases in which surgery was not an option. Regarding patients with low back disc herniation, factors associated with failure to achieve a disability outcome were male gender, low schooling level, high pain intensity, and generalized pain location. |
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