Comprehensive Specialty Care, Edmond, OK.
Department of Neurological Surgery, UC Davis, Cannery Building, Spine Center, Sacramento, CA.
Pain Physician. 2024 Sep;27(7):401-413.
Lumbar disc herniation (LDH) occurs when the central disc material, primarily the nucleus pulposus, is displaced beyond the outer annulus, compressing the spinal nerve roots. LDH symptoms, including radicular leg pain, radiculopathy, and low back pain, are associated with considerable disease burden and the significant utilization of health care resources.
Provide overview of the current treatment landscape for LDH, identify unmet needs, and describe emerging treatments.
Narrative literature review.
A review of literature concerning available LDH treatments and associated outcomes was conducted in PubMed to identify areas of unmet need. Some key words included "lumbar disc herniation," "radicular leg pain," "sciatica," "treatment," "therapy," and "burden."
For patients who do not respond to conservative therapy, epidural steroid injections (ESIs) are widely used for persistent LDH symptoms. While ESIs provide short-term improvements in radicular pain, evidence that ESIs bestow sustained benefits is limited. ESIs are not approved by the US Food and Drug Administration (FDA) and, in rare cases, carry risks of infection and neurological injury, as well as the potential for long-term systemic effects of glucocorticoids. In cases when nonsurgical treatment fails to relieve symptoms, lumbar discectomy can provide rapid pain relief; however, in addition to the risk of intraoperative complications, the long-term consequences of lumbar discectomy may include recurrent pain or herniation, revision discectomy, loss of disc height, and Modic changes. Treatments for LDH in late-stage clinical development include sustained-release ESI formulations and a novel agent for chemonucleolysis, a nonsurgical method of minimizing the volume of the displaced nucleus pulposus. Emerging minimally invasive therapies that address the underlying pathophysiology of the disease have the potential to bridge the gap between symptomatic treatments and surgery.
Because this paper was a narrative review, literature search and selection processes were not systematic in nature. The evidence regarding the long-term efficacy of some treatments, such as discectomy, was limited by the high rates of crossover between the treatment groups.
The lack of sustained benefits associated with ESIs and the risks associated with surgery underscore the unmet need for novel, minimally invasive interventional therapies able to address the underlying nerve root compression in LDH.
当中央椎间盘物质（主要是髓核）移位超出外纤维环时，会发生腰椎间盘突出症（LDH），压迫脊神经根。LDH 症状，包括神经根性腿部疼痛、神经根病和腰痛，与相当大的疾病负担和大量医疗资源的利用有关。
概述 LDH 的当前治疗现状，确定未满足的需求，并描述新兴治疗方法。
叙述性文献综述。
在 PubMed 中检索有关可用的 LDH 治疗方法和相关结果的文献，以确定未满足的需求领域。一些关键词包括“腰椎间盘突出症”、“神经根性腿部疼痛”、“坐骨神经痛”、“治疗”、“疗法”和“负担”。
对于对保守治疗无反应的患者，硬膜外类固醇注射（ESI）广泛用于持续性 LDH 症状。虽然 ESI 可短期改善神经根疼痛，但 ESI 带来持续益处的证据有限。ESI 未获得美国食品和药物管理局（FDA）的批准，并且在极少数情况下，存在感染和神经损伤的风险，以及糖皮质激素的长期全身作用的潜力。在非手术治疗无法缓解症状的情况下，腰椎间盘切除术可以迅速缓解疼痛；然而，除了术中并发症的风险外，腰椎间盘切除术的长期后果可能包括复发疼痛或突出、翻修椎间盘切除术、椎间盘高度丧失和 Modic 改变。处于临床开发后期的 LDH 治疗方法包括持续释放 ESI 制剂和一种新型化学核溶解剂，这是一种减少移位髓核体积的非手术方法。针对疾病潜在病理生理学的新兴微创治疗方法有可能在症状治疗和手术之间架起桥梁。
由于本文是一篇叙述性综述，文献检索和选择过程并非系统性的。一些治疗方法（如椎间盘切除术）的长期疗效证据受到治疗组之间高交叉率的限制。
ESI 缺乏持续获益和手术相关风险突出表明，需要新型微创介入治疗方法来解决 LDH 中的神经根受压根本问题。
