Abstract
Lumbar disc herniation (LDH) is one of the most common spinal pathologies and can be associated with debilitating pain and neurological dysfunction. Discectomy is the primary surgical intervention for LDH and is typically successful. Yet, some patients experience recurrent LDH (RLDH) after discectomy, which is associated with worse clinical outcomes and greater socioeconomic burden. Large defects in the annulus fibrosis are a significant risk factor for RLDH and present a critical treatment challenge. It is essential to identify reliable and cost-effective treatments for this at-risk population. A systematic review of the PubMed and Embase databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies describing the treatment of LDH patients with large annular defects. The incidence of large annular defects, measurement technique, RLDH rate, and reoperation rate were compiled and stratified by surgical technique. The risk of bias was scored for each study and for the identification of RLDH and reoperation. Study heterogeneity and pooled estimates were calculated from the included articles. Fifteen unique studies describing 2,768 subjects were included. The pooled incidence of patients with a large annular defect was 44%. The pooled incidence of RLDH and reoperation following conventional limited discectomy in this population was 10.6% and 6.0%, respectively. A more aggressive technique, subtotal discectomy, tended to have lower rates of RLDH (5.8%) and reoperation (3.8%). However, patients treated with subtotal discectomy reported greater back and leg pain associated with disc degeneration. The quality of evidence was low for subtotal discectomy as an alternative to limited discectomy. Each report had a high risk of bias and treatments were never randomized. A recent randomized controlled trial with 550 subjects examined an annular closure device (ACD) and observed significant reductions in RLDH and reoperation rates (>50% reduction). Based on the available evidence, current discectomy techniques are inadequate for patients with large annular defects, leaving a treatment gap for this high-risk population. Currently, the strongest evidence indicates that augmenting limited discectomy with an ACD can reduce RLDH and revision rates in patients with large annular defects, with a low risk of device complications.
Highlights
BackgroundLumbar disc herniation (LDH) is one of the most common spinal pathologies and can be associated with debilitating pain and neurological dysfunction
Two studies used a threshold of 5 mm and one study used a threshold of 4 mm, but the precision of these measurements is unclear
A logistic regression of recurrent LDH (RLDH) risk vs. annular defect size would be performed across a large number of patients, along with interobserver repeatability of the measurements, to identify the potential size threshold for at-risk defects, but no studies have attempted this type of analysis
Summary
BackgroundLumbar disc herniation (LDH) is one of the most common spinal pathologies and can be associated with debilitating pain and neurological dysfunction. It is estimated that 500,000 patients undergo surgery for disc herniation annually in the United States, while another one million receive non-operative care [1,2]. Management of symptomatic LDH usually progresses through a step-wise non-operative algorithm and may be followed by surgery if symptoms persist for more than six weeks or are associated with neurological deficit or unbearable pain. The least aggressive discectomy technique, sequestrectomy or fragmentectomy, removes only the protruding disc without invasion of the intervertebral disc space. Limited discectomy, which is often regarded as the conventional gold standard technique, is a compromise between sequestrectomy and subtotal discectomy, where the protruding disc and only loose nuclear material from the intervertebral space are removed [5]
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