Back Pain: Herniated Disc Treatment

Zhonghua Yi Xue Za Zhi. 2011 Jan 4;91(1):23-7.


[Quantitative evaluation for diagnostic efficacy of computed tomography and magnetic resonance imaging in patients with lumbar disc herniation].


 [Article in Chinese]


Yu XW, Niu G, Yang J, Ni L, Zhang WS, Guo YM.





PET-CT Department, First Hospital of Medical College of Xi’an Jiaotong University, Xi’an 710061, China.







To evaluate the diagnostic performances of CT and MRI in patients with lumbar intervertebral disc herniation through the Meta analytical method.




The relevant English and Chinese articles published between 1980 and 2010 were searched in PubMed, Medline, Ovid database, Cochrane library and Chinese Periodical Web. According to the criteria for diagnostic researches published by Cochrane Method Group on Screening and Diagnostic Tests, each article was critically appraised and screened with regards to the absolute numbers of true-positive, false-negative, true-negative and false-positive. Statistical analysis was performed by the Meta-Disc version 1.4, SPSS 13.0 and Comprehensive Meta-analysis version II. Heterogeneity was tested and publication bias analyzed. And the pooled weighted sensitivity and specificity and the corresponding 95%CI were calculated. The summary receiver operating characteristic (SROC) curve was performed and the area under the curve (AUC) calculated to summarize and evaluate the diagnostic efficiency of CT and MRI in lumbar intervertebral disc herniation. Finally a sensitivity analysis was performed.




According to the criteria of internalization, 9 articles were included. Among them, the themes were CT (n = 3), MRI (n = 3) and CT & MRI (n = 3). Eight was prospectively studied and one retrospectively. At the diagnosis of lumbar intervertebral disc herniation, the pooled weighted sensibility and specificity and 95% confidence interval and area under SROC curve for CT to the lumbar intervertebral disc herniation was 0.73 (0.68 – 0.77), 0.78 (0.72 – 0.82) and 83.5% respectively. The MRI was 0.88 (0.83 – 0.91), 0.79 (0.71 – 0.87) and 88.8% respectively. There was statistically significant difference in the pooled weighted sensibility (P < 0.05); No statistically significant difference was found in the pooled weighted specificity (P > 0.05); And there was statistically significant difference in the AUC curve (P < 0.05).




After a meta-analysis of the diagnostic value of CT and MRI for the lumbar intervertebral disc herniation, MRI is more accurate than CT in the diagnosis of lumbar intervertebral disc herniation.



PMID: 21418957






Cochrane Database Syst Rev. 2010 Feb 17;(2):CD007431.


Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain.


van der Windt DA, Simons E, Riphagen II, Ammendolia C, Verhagen AP, Laslett M, Devillé W, Deyo RA, Bouter LM, de Vet HC, Aertgeerts B.





Department of Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK, ST5 5BG.







Low-back pain with leg pain (sciatica) may be caused by a herniated intervertebral disc exerting pressure on the nerve root. Most patients will respond to conservative treatment, but in carefully selected patients, surgical discectomy may provide faster relief of symptoms. Primary care clinicians use patient history and physical examination to evaluate the likelihood of disc herniation and select patients for further imaging and possible surgery.




(1) To assess the performance of tests performed during physical examination (alone or in combination) to identify radiculopathy due to lower lumbar disc herniation in patients with low-back pain and sciatica;(2) To assess the influence of sources of heterogeneity on diagnostic performance.




We searched electronic databases for primary studies: PubMed (includes MEDLINE), EMBASE, and CINAHL, and (systematic) reviews: PubMed and Medion (all from earliest until 30 April 2008), and checked references of retrieved articles.




We considered studies if they compared the results of tests performed during physical examination on patients with back pain with those of diagnostic imaging (MRI, CT, myelography) or findings at surgery.




Two review authors assessed the quality of each publication with the QUADAS tool, and extracted details on patient and study design characteristics, index tests and reference standard, and the diagnostic two-by-two table. We presented information on sensitivities and specificities with 95% confidence intervals (95% CI) for all aspects of physical examination. Pooled estimates of sensitivity and specificity were computed for subsets of studies showing sufficient clinical and statistical homogeneity.




We included 16 cohort studies (median N = 126, range 71 to 2504) and three case control studies (38 to100 cases). Only one study was carried out in a primary care population. When used in isolation, diagnostic performance of most physical tests (scoliosis, paresis or muscle weakness, muscle wasting, impaired reflexes, sensory deficits) was poor. Some tests (forward flexion, hyper-extension test, and slump test) performed slightly better, but the number of studies was small. In the one primary care study, most tests showed higher specificity and lower sensitivity compared to other settings.Most studies assessed the Straight Leg Raising (SLR) test. In surgical populations, characterized by a high prevalence of disc herniation (58% to 98%), the SLR showed high sensitivity (pooled estimate 0.92, 95% CI: 0.87 to 0.95) with widely varying specificity (0.10 to 1.00, pooled estimate 0.28, 95% CI: 0.18 to 0.40). Results of studies using imaging showed more heterogeneity and poorer sensitivity. The crossed SLR showed high specificity (pooled estimate 0.90, 95% CI: 0.85 to 0.94) with consistently low sensitivity (pooled estimate 0.28, 95% CI: 0.22 to 0.35).Combining positive test results increased the specificity of physical tests, but few studies presented data on test combinations.




When used in isolation, current evidence indicates poor diagnostic performance of most physical tests used to identify lumbar disc herniation. However, most findings arise from surgical populations and may not apply to primary care or non-selected populations. Better performance may be obtained when tests are combined.



Comment in

Evid Based Med. 2010 Jun;15(3):82-3.



PMID: 20166095

Praxis (Bern 1994). 2011 Nov 30;100(24):1475-85.


[The lumbar disc herniation – management, clinical aspects and current recommendations].


 [Article in German]


Stienen MN, Cadosch D, Hildebrandt G, Gautschi OP.





Klinik für Neurochirurgie, Kantonsspital St. Gallen.





Lumbar disc herniation has a high prevalence and strong social-medical impact. Patients suffer from lower back pain that radiates from the spine. Loss of sensation or paresis adds to the clinical picture. The diagnosis should be confirmed by imaging in patients considered for surgery. High remission rates initially warrant conservative treatment (adequate analgesia and physiotherapy) in many patients. If this treatment does not lead to significant alleviation within 5-8 weeks, surgery should be performed to reduce the risk of chronic nerve affection. Posterior interlaminar fenestration is the intervention primarily conducted for this diagnosis. A relapse in the same region occurs in up to 10% of patients after months through years, which sometimes necessitates a reoperation if symptoms are pertinent.



PMID: 22124958

Spine (Phila Pa 1976). 2012 Jan 15;37(2):E109-18.


Evaluation of treatment effectiveness for the herniated cervical disc: a systematic review.


Gebremariam L, Koes BW, Peul WC, Huisstede BM.





Erasmus Medical Center, Department of General Practice, Rotterdam, The Netherlands.







Systematic review.




To assess the effectiveness of interventions for treating cervical disc herniation.




Cervical disc herniation is 1 of the 23 specific disorders included in the CANS (Complaints of the Arm, Neck, and/or Shoulder) model. Treatment options range from conservative to surgical, but evidence for the effectiveness of these interventions is not yet well documented.




The Cochrane Library, MEDLINE, EMBASE, PEDro, and CINAHL were searched for relevant systematic reviews and randomized clinical trials (RCTs) up to February 2009. Two reviewers independently selected relevant studies, assessed the methodological quality, and extracted data.




Pooling of the data was not possible; thus, a best-evidence synthesis was used to summarize the results. Of the 11 RCTs included, 1 compared conservative with surgical intervention, and 10 compared various surgical interventions. No evidence was found for the effectiveness of conservative treatment (nonsteroidal anti-inflammatory drugs, cortisonics, and physical therapy) compared with percutaneous nucleoplasty. Moderate evidence was found for the effectiveness of anterior cervical discectomy with fusion (ACDF) using a titanium cage compared with ACDF using polymethyl methacrylate, and for BRYAN cervical disc (Medtronic Sofamor Danek, Memphis, TN) prostheses compared with ACDF using allograft bone and plating. No outcomes regarding adjacent-level disease were reported. There is conflicting evidence for the effectiveness of ACD compared with ACDF. Only limited or no evidence was found for the other surgical interventions.




No evidence for effectiveness of conservative treatment compared with surgery was found. Although there is moderate evidence for the effectiveness of some surgical interventions, no unequivocal evidence for the superiority of 1 particular surgical treatment was found. Worldwide, most patients receive supplementary implants; however, cervical discectomy without graft may be preferred because of similar outcomes, lower costs, and possibly a lower risk of adjacent-level disease. More high-quality RCTs using validated outcome measures (including adjacent level disease) are needed.



PMID: 21587105

Pain Physician. 2012 Mar;15(2):E115-29.


Ozone Therapy as a Treatment for Low Back Pain Secondary to Herniated Disc: A Systematic Review and Meta-analysis of Randomized Controlled Trials.


De Oliveira Magalhaes FN, Dotta L, Sasse A, Teixera MJ, Fonoff ET.





Hospital das Clnicas University of Sao Paulo Medical School, Sao Paulo, Brazil.







Low back pain (LBP) is one of the most common and important health problems affecting the population worldwide and remains mostly unsolved. Ozone therapy has emerged as an additional treatment method. Questions persist concerning its clinical efficacy.




The purpose of our study was to evaluate the therapeutic results of percutaneous injection of ozone for low back pain secondary to disc herniation.




A systematic review and meta-analysis of randomized controlled trials.




A comprehensive literature search was conducted using all electronic databases from 1966 through September 2011. The quality of individual articles was assessed based on the modified Cochrane review criteria for randomized trials and criteria from the Agency for Healthcare Research and Quality. OUTCOME PARAMETERS: The outcome measure was short-term pain relief of at least 6 months or long-term pain relief of more than 6 months.




Eight observational studies were included in the systematic review and 4 randomized trials in the meta-analysis. The indicated level of evidence for long-term pain relief was II-3 for ozone therapy applied intradiscally and II-1 for ozone therapy applied paravertebrally. The grading of recommendation was 1C for intradiscal ozone therapy and 1B for paravertebral ozone therapy.




The main limitations of this review are the lack of precise diagnosis and the frequent use of mixed therapeutic agents. The meta-analysis included mainly active-control trials. No placebo-controlled trial was found.




Ozone therapy appears to yield positive results and low morbidity rates when applied percutaneously for the treatment of chronic low back pain.



PMID: 22430658

Zhongguo Gu Shang. 2010 Sep;23(9):696-700.


[Systematic review of clinical randomized controlled trials on manipulative treatment of lumbar disc herniation].


 [Article in Chinese]


Li L, Zhan HS, Zhang MC, Chen B, Yuan WA, Shi YY.





Department of Orthopaedics, Shuguang Hospital Affiliated to Shanghai University of TCM, Shanghai 200021, China.







To evaluate the efficacy and safety of the manipulative treatment on lumbar disc herniation and analyze the current status of clinical studies.




The PubMed, OVID, Cochrane Library, CBM – disc database, CNKI database and VIP Database were retrieved, and 832 literatures on manipulative treatment for lumbar disc herniation were collected, in which 8 articles met the inclusion criteria. Cochrane systematic review was used to evaluate the quality; and RevMan 4.2 was used for Meta Analysis of Literatures.




There were total 911 patients in the 8 articles. The summary OR for the combined cure rate of the 8 articles was 3.65, and the 95% CI was [2.15, 6.20]. The summary OR for the combined efficiency was 3.56, and the 95% CI was [2.35, 5.38]. The cure rate and effective rate of the patients in manipulative group were superior to those of patients treated with other methods such as drugs, traction, acupuncture, microwave thermotherapy (all the methods were called as “other therapies”).




This study shows that manipulative treatment on lumbar disc herniation is safe, effective, and both cure rate and the effective rate is better than other therapies. But the number of documents is limited and the quality is not very high, and the conclusion is still uncertain, high-quality evidence is needed to be further validated.



PMID: 20964003

Eur Spine J. 2011 Apr;20(4):513-22. Epub 2010 Oct 15.


Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review.


Jacobs WC, van Tulder M, Arts M, Rubinstein SM, van Middelkoop M, Ostelo R, Verhagen A, Koes B, Peul WC.





Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300 RC Leiden, The Netherlands.





The effectiveness of surgery in patients with sciatica due to lumbar disc herniations is not without dispute. The goal of this study was to assess the effects of surgery versus conservative therapy (including epidural injections) for patients with sciatica due to lumbar disc herniation. A comprehensive search was conducted in MEDLINE, EMBASE, CINAHL, CENTRAL, and PEDro up to October 2009. Randomised controlled trials of adults with lumbar radicular pain, which evaluated at least one clinically relevant outcome measure (pain, functional status, perceived recovery, lost days of work) were included. Two authors assessed risk of bias according to Cochrane criteria and extracted the data. In total, five studies were identified, two of which with a low risk of bias. One study compared early surgery with prolonged conservative care followed by surgery if needed; three studies compared surgery with usual conservative care, and one study compared surgery with epidural injections. Data were not pooled because of clinical heterogeneity and poor reporting of data. One large low-risk-of-bias trial demonstrated that early surgery in patients with 6-12 weeks of radicular pain leads to faster pain relief when compared with prolonged conservative treatment, but there were no differences after 1 and 2 years. Another large low-risk-of-bias trial between surgery and usual conservative care found no statistically significant differences on any of the primary outcome measures after 1 and 2 years. Future studies should evaluate who benefits more from surgery and who from conservative care.



PMID: 20949289


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