A systematic review of randomised clinical trials using posterior discectomy to treat lumbar disc herniations

Abstract

The focus of this study was to examine the safety and effectiveness of three different discectomy techniques using a posterior approach for the treatment of herniated lumbar discs. There are only a small number of prospective randomised studies comparing posterior lumbar discectomy techniques, and no recent systematic review has been published on this matter. Using the Cochrane Collaboration guidelines, all randomised or "quasi-randomised" clinical trials, comparing classic, microsurgical, and endoscopic lumbar discectomies using a posterior approach were systematically reviewed. No statistically significant differences were found between these techniques regarding improvement in pain, sensory deficits, motor strength, reflexes, and patient satisfaction. Current data suggest that the microsurgical and endoscopic techniques are superior to the classic technique for the treatment of single level lumbar disc herniations with respect to volume of blood loss, systemic repercussions, and duration of hospital stay. All three surgical techniques were found to be effective for the treatment of single level lumbar disc herniations in patients without degenerative vertebral deformities. No conclusions could be drawn from the clinical randomised studies reviewed regarding the safety of the three techniques studied due to insufficient data on postoperative complications.

Figures

Fig. 1

Forest plot representation of a single study (Katayama et al. [15]) comparing classic and microdiscectomy. The expected outcome was mean amount of bleeding. A statistically significant difference was found in favour of the microscopic technique (WMD [PMP] 14.00 [95%CI 10.40, 17.60])

Fig. 2

Forest plot representation of a single study (Huang et al. [13]) comparing classic and endoscopic discectomy. The expected outcome was intraoperative blood loss (ml). A statistically significant difference was found in favour of the endoscopic technique (WMD [PMP] 102.50 [95%CI 25.50, 180.50])

Fig. 3

Forest plot representation of a single study (Kelly et al. [16]) comparing classic and microdiscectomy. The expected outcome was change in body temperature. A statistically significant difference was found in favour of the microscopic technique in the subcategories 24 hours postoperative (WMD [PMP] 0.51 [95%CI 0.30, 0.72]), 36 hours postoperative (WMD [PMP] 0.76 [95%CI 0.64, 0.88]), 48 hours postoperative (WMD [PMP] 0.72 [95%CI 0.53, 0.91]), and 60 hours postoperative (WMD [PMP] 33.25 [95%CI 33.03, 33.47])

Fig. 4

Forest plot representation of a single study (Huang et al. [13]) comparing classic and endoscopic discectomy. The expected outcome was postoperative systemic response. A statistically significant difference was found in favour of the endoscopic technique regarding CRP levels (C-reactive protein) 24 hours postoperative (WMD [PMP] 13.94 [95%CI 4.60, 23.28]) and the levels of IL-6 (interleukin 6) 24 hours postoperative (WMD [PMP] 12.10 [95%CI 3.38, 18.44])

Fig. 5

Meta-analysis of two studies (Mayer et al. [18] and Righesso Neto et al. [23]) that compared microscopic and endoscopic discectomy. The expected outcome was return to work 1 year postoperative. A statistically significant difference was found in favour of the endoscopic technique (RR 0.68 [95%CI 0.49, 0.96])

Fig. 6

Forest plot representation of a single study (Huang et al. [13]) comparing classic and endoscopic discectomy. The expected outcome was duration of hospital stay (days). A statistically significant difference was found in favour of the endoscopic technique (WMD [PMP] 2.35 [95%CI 0.87, 3.83])