An evidence-based review of the literature on the consequences of conservative versus aggressive discectomy for the treatment of primary disc herniation with radiculopathy

BACKGROUND CONTEXT: 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. PURPOSE: 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. PATIENT SAMPLE: Patients with primary lumbar disc herniation with radiculopathy. OUTCOME MEASURES: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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. (C) 2009 Elsevier Inc. All rights reserved.