Diese Präsentation wurde erfolgreich gemeldet.
Wir verwenden Ihre LinkedIn Profilangaben und Informationen zu Ihren Aktivitäten, um Anzeigen zu personalisieren und Ihnen relevantere Inhalte anzuzeigen. Sie können Ihre Anzeigeneinstellungen jederzeit ändern.
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 ...
Levels of Evidence
Level 1 High quality RCT
Level 2
Prospective
comparative
Low quality RCT
Level 3
Retrospective
comparat...
The Evidence
RCTs 5
Prospective comparative 4
Retrospective comparative 1
Surgery versus Nonop treatment
RCT
126 patients
Discectomy or Physical therapy
Outcome measures - Unvalidated measure (Poor, Fair, Good, Ex)
10 year FU
1...
RCT
100 patients failed noninvasive therapy for 6 weeks
Discectomy or ESI
Outcome measures - ODI, VAS, Pt satisfaction
2-3...
RCT
56 patients with radicular pain for 6-8 wks
Discectomy or Physical therapy
Outcome measures - ODI and VAS
2 years FU
D...
RCT
208 patients
Discectomy or Nonoperative Rx
Outcome measures - ODI and VAS
2 years FU
Discectomy better at 6 months
At ...
RCT (multicenter)
501 patients
Discectomy (245) or Nonoperative Rx (256)
Outcome measures - SF36, ODI, Self reported outco...
f multiple RCTs over last 2 decades are showing no difference
Then why do discectomy at all ?
Patients with
radiculopathy
(100)
Surgery
(50)
Conservative Rx
(50)Randomized
Ideally, at End of Study
Patients with
radiculopathy
(100)
Surgery
(30)
Conservative Rx
(30)Randomized
In real life
Intent to Treat
Cross over
At best these RCT studies are Level 2
Prospective cohort
Level 2
Summary Follow up
Spengler et. al. 77% good result with surgery Minimum 1 year
Atlas et. al.
(M...
Retrospective cohort study
Out of 58 patient in conservative group 90% had good results
However, 347 patients were enrolle...
Current Recommendation
Discectomy is suggested to provide more effective
symptom relief than medical/interventional care f...
What about patients with motor deficit ?
Is surgery better ?
Neurological deficit
Complete motor recovery
Weber (1983)
96% non operative cohort
94% operative cohort
Hekelius (1970)
77...
Natural history
severe deficits MRC<3
Buttermann (2004)
100% recovery with surgery
0% with nonoperative treatment
Dubourg ...
Systematic Review
7 studies with 354 patients
Grade 3 or worse
Surgery - 38% recovery (at least MRC 4 in 52%)
Nonoperative...
Guidelines
Grades of Recommendation
Grade A 2 or more consistent Level 1 studies
Grade B Two or more consistent Level 2 or 3 studies
...
Pharmacological
treatment
Grade I
Insufficient evidence
(Gabapentin, Steroids,
Amytriptyline, NSAIDS)
Physical therapy Gra...
TFESI
(short term)
Grade A
TFESI provide short term
pain relief (2-4 weeks)
TFESI
(long term)
Insufficient evidence
Insuff...
Nucleoplasty Grade I
Insufficient evidence for
or against
Plasma disc
decompression
Grade I
Insufficient evidence for
or a...
Intradiscal Ozone Grade I
Insufficient evidence for
or against
Automated percutanous
discectomy
(versus open discectomy)
G...
Thank you
www.spinemumbai.in
Twitter @kcspine
kshitijchaudhary.wordpress.com
Nonoperative care versus surgery in lumbar disc herniation with radiculopathy. what is the evidence?
Nächste SlideShare
Wird geladen in …5
×

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

2.074 Aufrufe

Veröffentlicht am

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.

Veröffentlicht in: Gesundheit & Medizin
  • Loggen Sie sich ein, um Kommentare anzuzeigen.

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

×