1. EBS Presentation
Indications and timing of surgery for lumbar
disc herniation
Johnny Wong
20th October, 2011
Advanced Scholar: Dr Kevin Seex

2. 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?

3. 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

4. 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”

5. • 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 Convservative
Optimal timing not investigated • Discussion (on discectomy) :
– Prolonging surgery may delay recovery
but does not produce long-term harm
– Primary indication – Rapid relief of pain

6. Ovid Medline
6 Useful
articles:
Early Surgery
vs
Conservative
Looked up
complete
references:
Another 2
articles found

7. Scopus & Google scholar
• Scopus:
– Searched from reference list from medline useful
articles
– 3 more useful articles
• Google scholar
– Nil further useful articles

8. • 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

9. • 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

11. • RCT: 283 patients (141 surgery vs 142 conservative); 9 centres
• Symptoms for 6 – 12 weeks; surgery within 2 weeks of
randomisation; 85% open microdiscectomy

12. • 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

13. • 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”

14. • 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

16. • As treated analyses at 4
years:
• Significant differences in
disability and SF-36
• Non-significance if
intention to treat.

17. 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