Watters William C, McGirt Matthew J
Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX 77030, USA.
Spine J. 2009 Mar;9(3):240-57. doi: 10.1016/j.spinee.2008.08.005. Epub 2008 Sep 21.
It remains unknown whether aggressive disc removal with curettage versus conservative removal of a disc fragment with little disc invasion provides a better outcome for the treatment of lumbar disc herniation with radiculopathy.
Determine the level of evidence within the clinical literature that supports the performance of a conservative versus aggressive technique for discectomy.
STUDY DESIGN/SETTING: Systematic evidence-based review of clinical literature.
Patients with primary lumbar disc herniation with radiculopathy.
Operative time, return to work status, recurrent disc herniation, self-reported, and functional measures assessed less than 2 years (short term) and greater than 2 years (long term) after surgery.
Systematic Medline search was performed to identify all published studies relating to outcome after aggressive or conservative discectomy. Levels of evidence (I-V) were assessed for each study and grades of recommendation were generated (Good, Fair, Poor, Insufficient evidence) based on the NASS Clinical Guidelines' Levels of Evidence and Grades of Recommendation.
There is fair evidence that conservative discectomy will result in shorter operative times and a quicker return to work despite similar lengths of hospital stay, similar pain levels at discharge, similar 6-month functional status, and a similar 2-year incidence of persistent/recurrent back and leg pain. There is poor quality evidence that conservative discectomy will result in a lower incidence of recurrent back pain beyond 2 years postoperatively. There is fair quality evidence that conservative discectomy will result in a higher incidence of recurrent disc herniation.
There are no Level I studies to support conservative versus aggressive discectomy for the treatment of primary disc herniation. However, systematic review of the literature suggests that conservative discectomy may result in shorter operative time, quicker return to work, and a decreased incidence of long-term recurrent low back pain but with an increased incidence of recurrent disc herniation. Prospective randomized trails are needed to firmly assess this possible benefit.
对于腰椎间盘突出症伴神经根病的治疗，与仅轻微侵犯椎间盘的保守性椎间盘碎片切除术相比，采用刮匙进行积极的椎间盘切除术是否能带来更好的疗效仍不明确。
确定临床文献中支持保守性与积极性椎间盘切除术的证据水平。
研究设计/设置：基于循证医学的临床文献系统评价。
原发性腰椎间盘突出症伴神经根病患者。
手术时间、恢复工作状态、复发性椎间盘突出症、自我报告以及术后不到2年（短期）和超过2年（长期）评估的功能指标。
进行系统的Medline检索，以识别所有与积极或保守性椎间盘切除术后结局相关的已发表研究。根据北美脊柱协会（NASS）临床指南的证据水平和推荐等级，对每项研究的证据水平（I-V级）进行评估，并生成推荐等级（良好、中等、差、证据不足）。
有中等证据表明，尽管住院时间相似、出院时疼痛程度相似、6个月功能状态相似以及2年持续性/复发性腰腿痛发生率相似，但保守性椎间盘切除术将导致手术时间更短且恢复工作更快。有低质量证据表明，保守性椎间盘切除术将导致术后2年以上复发性背痛的发生率更低。有中等质量证据表明，保守性椎间盘切除术将导致复发性椎间盘突出症的发生率更高。
尚无I级研究支持保守性与积极性椎间盘切除术治疗原发性椎间盘突出症。然而，文献的系统评价表明，保守性椎间盘切除术可能导致手术时间更短、恢复工作更快，以及长期复发性下腰痛的发生率降低，但复发性椎间盘突出症的发生率增加。需要进行前瞻性随机试验来确切评估这种可能的益处。
