ABSTRACT
BACKGROUND AND OBJECTIVES: Herniated disc is a common pathology, affecting about 5 to 10 cases per 1000 adults annually. A conservative or a surgical approach to treatment can be adopted. The present study’s objective was to evaluate each of these approaches.
CONTENTS: An integrative literature review was carried out, aiming to understand which treatment provides greater benefits in the short, medium, and long term for patients with low back disc herniation. Of the 4941 articles found, 4852 were excluded by title, 75 by abstract and 14 were selected for the study. Of these 14 studies, 10 considered the conservative approach more beneficial to patients, while 4 considered the surgical conduct more beneficial.
CONCLUSION: Surgical treatment is a good option for those cases in which patients have debilitating pain and need rapid pain relief. However, in the long run, there is no superiority of surgery over conservative treatment.
Keywords: Intervertebral disc displacement; Low back pain; Surgical procedures
RESUMO
JUSTIFICATIVA E OBJETIVOS: A hérnia de disco é frequente na população, com cerca de 5 a 10 casos anualmente em cada 1.000 adultos. O tratamento pode ser feito de modo conservador ou cirúrgico. O objetivo deste estudo foi avaliar cada uma destas técnicas.
CONTEÚDO: Realizou-se uma revisão integrativa de literatura, objetivando elucidar qual tratamento proporciona maiores benefícios a curto, médio e longo prazo para os pacientes com hérnia de disco lombar. Dos 4.941 artigos encontrados, 4.852 foram excluídos pelo título, 75 pelo resumo e 14 foram selecionados para o estudo. Dos 14 estudos analisados, 10 consideraram a conduta conservadora como mais benéfica aos pacientes e 4 consideraram a conduta cirúrgica mais benéfica.
CONCLUSÃO: O tratamento cirúrgico é uma boa opção para os casos em que os pacientes apresentam dores debilitantes e que necessitam de alívio rápido da dor. Entretanto, a longo prazo, não há superioridade da cirurgia em relação ao tratamento conservador.
Descritores: Deslocamento do disco intervertebral; Dor lombar; Procedimentos cirúrgicos
INTRODUCTION
Low back pain, or lumbago, and low back pain radiating to the lower limbs, or lumbosciatalgia, are common complaints in medical care. About 85% of cases involve low back disc herniation1, with an incidence of 5 to 20 cases in every 1000 adults2, being more common in people in the third to fifth decade of life, with a proportion twice as high in the male gender2.
The intervertebral disc is composed of the fibrous ring and the nucleus pulposus3. The fibrous ring rupture is more frequent in the posterior part, where the collagen bundles are less dense, resulting in the expulsion of the nucleus pulposus3. Clinically there is increased pain when sitting, coughing or sneezing, and relief on standing or walking. Radiation of pain to the lower extremity and neurological symptoms such as numbness, motor weakness, and urinary or fecal incontinence are signs of advanced disease with disc prolapse, nerve root compression, or spinal stenosis4. The presence of disc protrusion doesn’t necessarily mean that the patient will be symptomatic; in many cases it may be just an incidental finding on imaging exams2. There may be spontaneous regression of the herniated material and consequent improvement of symptoms, so that in more than 85% of patients the symptoms caused by acute herniated disc will resolve in 8 to 12 weeks, with no specific treatment2.
Considering the possibility of conservative or surgical management, there are doubts as to which is the best for these patients in the short, medium and long term.
The objective of this studye was to compare these two approaches to the available evidence in the literature.
CONTENTS
In order to perform the integrative review, first the problem was identified, then a literature search was performed, with delimitation of descriptors, databases and inclusion and exclusion criteria. Following that, the data obtained was evaluated and analyzed and the final text was composed.
The studies search occurred in September and October 2020, using the keywords: Conservative Treatment, Surgical procedures, Nucleus Pulposus, and intervertebral disc displacement. Free terms do not present in DeCS were also used.
Studies in Portuguese, English, and Spanish published in the last five years that compared surgical and conservative treatment for lumbar disc herniation were included. Articles that included patients with radicular symptoms of diseases other than lumbar disc herniation, that included children or adolescents, and articles about cervical or thoracic disc herniation were excluded. A total of 4941 articles were found in the Scielo, Pubmed, Cochrane, CAPES, LILACS, and Revista Science platforms. Of those, 4852 were excluded by title, 76 by abstract, and only 14 were selected for meeting the inclusion criteria. Tw o authors acting independently examined the titles and abstracts of the articles obtained through the electronic search. The third author did a full reading of the final text.
The data were not pooled due to the heterogeneity of the methodology used in each article. Figure 1 presents the summary of the article selection process.
RESULTS
Table 1 shows the authors, surgical treatment, conservative treatment, and the main conclusions of each study.
A cohort study5 that retrospectively analyzed 277.941 symptomatic patients diagnosed with low back disc herniation found that 97% of them obtained success with conservative treatment and only 3% underwent surgery. According to the study, independent predictors of conservative treatment failure were male gender and previous opioid use. The study concluded that the best option for initial treatment is conservative treatment, since a high percentage of patients recover or experience gradual or substantial improvement within 4-6 weeks of treatment1,7,8.
When comparing short-, medium-, and long-term outcomes, a systematic review published in 2019 found that surgery provides significantly greater short- and medium-term pain reduction, but this difference did not persist on the long term9. A cohort study with 370 patients showed that surgical treatment decreased lower back pain by 6 weeks more than conservative treatment; however, after 3 months, no relevant clinical difference was observed between the groups10. Another systematic review, with a sample of 2271 patients, came to the same conclusion, because within 1 to 3 months and 3 to 6 months, pain assessed by the visual analog scale (VAS) showed better results in patients who underwent surgery, but in the long term the results were similar11.
Another study that assessed pain using the VAS, including 128 patients, 64 in the surgical group and 64 in the non-surgical group, concluded that at the end of the 6 months follow-up the patients who underwent surgery had a lower VAS score, which decreased from 7.7 at the beginning to 2.8 at the end of the study, compared to patients who received clinical treatment, whose pain decreased from 8 to 5.512. A meta-analysis13 that evaluated surgery with simple discectomy and discectomy with bone-anchored device versus continued conservative treatment, presented evidence that surgery is more effective for symptom relief than persisting with continued conservative treatment in cases where the patient is refractory to initial conservative treatment13.
The evaluation of the success or failure of disc protrusion treatment by the quantitative sensory test (QST), which uses different stimuli to evaluate the perception of temperature and pain, found no differences in all parameters evaluated at the 3 to 6 months follow-ups in patients treated conservatively with steroid injections or with surgical treatment14.
One of the studies compared total disc replacement surgery in 69 patients. In 57 patients who were treated conservatively there was no difference between surgery and conservative treatment at the 8-year follow-up, supporting the theory that the possible development of adjacent intervertebral disc degeneration is part of the natural course of disc degeneration, regardless of the treatment that was instituted15.
Surgery provided better results by decompressing the affected nerve root when the outcome analyzed was the improvement of neuropathic pain. A study16 that evaluated neuropathic pain using the Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) score found that the mean preoperative S-LANSS decreased from 11.4 to 7.5 one month after surgery, but a similar reduction was not observed in the group submitted to conservative treatment.
DISCUSSION
Low back pain caused by herniated disc impacts several areas of an individual’s life, especially between the 3rd and 5th decade of life2, when they are in an active working phase. There are reports of prodromal history of mild to moderate axial pain for months, followed by an acute episode of pain radiating to lower limbs, distinguishing lumbosciatalgia17. Knowing the treatment options and the right moment to indicate a certain therapy is essential to improve quality of life of these patients and to enable them to return to their work activities as soon as possible.
The evaluation of the success of therapy for lumbar disc herniation is heterogeneous because some articles10,11,13 used the pain scale, others9,10,11 applied quality of life questionnaires, such as the Short-Form Health Survey (SF-36), and disability level indexes, such as the Oswestry Disability Index, making it difficult to compare the results of the selected studies. In any case, it was clear that conservative treatment is the first option due to the benign nature of the disease and the high percentage of spontaneous regression of disc herniations1,7,8. On the other hand, there are cases in which surgical intervention is the absolute indication, such as cauda equina syndrome or significant paresis, which should be immediately operated8.
The ideal moment to indicate surgery in non-urgent cases is still uncertain, but conservative treatment for at least 6 weeks is recommended7. There is also the possibility of assessing the predictors of failure in prolonged conservative treatment, thus indicating surgery earlier. A cohort study18 showed that male gender, low education, intense and generalized pain are predictors of conservative treatment failure.
When comparing surgical and conservative treatment using pain scales, it was evidenced that surgery presents better results in the short and medium term; however, in the long term, patients had the same results, regardless of the type of treatment used9,10,11. Tis research is in agreement with classic studies that are emphatic in stating that after 1, 4 or 10 years of follow-up the comparative results between conservative and surgical treatment of herniated disc sciatalgia are statistically similar19.
Although MRI is an excellent method for diagnosing herniated disc, there is no indication for it to be used as a parameter of treatment failure or success, because most patients report symptom improvement long before any radiological improvement is seen20.
The prolonged physical therapy and rehabilitation program is more beneficial and successful for patients with a recent diagnosis of low back disc herniation than early surgical intervention, because it improves the functional capacity and facilitates return to work20.
CONCLUSION
Conservative treatment is the initial treatment recommended for all cases of disc herniation, because it provides an earlier return to work activities. Surgical treatment is a good option for those cases that present debilitating pain and need quick relief; nevertheless, in the long term, for a period of one year or more, surgery is not superior to conservative treatment. As with all treatment, the patient’s expectations and wishes must be taken into account when choosing different approaches.
REFERENCES
- 1 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.
- 2 Dydyk AM, Ngnitewe Massa R, Mesfin FB. Disc herniation. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021.
- 3 Junqueira LC. Histologia básica: texto e atlas. 13a ed. Rio de Janeiro; Guanabara Koogan; 2018.
- 4 Urits I, Capuco A, Sharma M, Kaye AD, Viswanath O, Cornett EM, et al. Stem cell therapies for treatment of discogenic low back pain: a comprehensive review. Curr Pain Headache Rep. 2019;23(9):65.
- 5 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.
- 6 Altun I, Yüksel KZ. Lumbar herniated disc: spontaneous regression. Korean J Pain. 2017;30(1):44-50.
- 7 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.
- 8 Clark R, Weber RP, Kahwati L. Surgical management of lumbar radiculopathy: a systematic review. J Gen Intern Med. 2020;35(3):855-64.
- 9 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.
- 10 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.
- 11 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.
- 12 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.
- 13 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.
- 14 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.
- 15 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.
- 16 Filho GR, Barros TE. Ortopedia e traumatologia. 1ª ed. Rio de Janeiro; Elsevier; 2018.
- 17 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.
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18 Kojima KE, Barros Filho TEP, Fernandes TD. Casos clínicos em ortopedia e traumatologia: guia prático para formação e atualização em ortopedia. 2009 [citado 8 de fevereiro de 2021]; Disponível em: https://repositorio.usp.br/item/001832832
» https://repositorio.usp.br/item/001832832 - 19 Turk O, Antar V, Yaldiz C. Spontaneous regression of herniated nucleus pulposus: the clinical findings of 76 patients. Medicine. 2019;98(8):e14667.
- 20 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.
Publication Dates
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Publication in this collection
17 Dec 2021 -
Date of issue
Oct-Dec 2021
History
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Received
13 Feb 2021 -
Accepted
17 Sept 2021