EUROPEAN JOURNAL OF PUBLIC HEALTH 1996; 6: 15-20

The effectiveness of treatment for the prolapsed lumbar intervertebral disc

A review of the literature
MERYL DEANE, ANNE). MOORE, ANDREW F. LONG, STEPHEN HARRISON
*

Literature relating to the management of prolapsed lumbar intervertebral discs was reviewed in order to assess the effectiveness of current medical care. Five aspects of care were addressed: the effectiveness of alternative forms of conservative treatment, the length of time necessary for a satisfactory trial of conservative management, the usefulness or otherwise of routine lumbar spine X-rays, the type of investigation best suited to confirm the nature and level of the lesion in cases where surgical intervention is considered and the form of intervention that provides the best outcome for the patient. Plain lumbar spine X-rays were found to be unnecessary as a routine investigation. All conservative treatment options were found to offer at most short-term benefit only and did not affect the long-term outcome. Computerized tomographic scans or magnetic resonance imaging are most suitable for providing confirmation of the level of the lesion. Myelograms should not be used routinely. Minimally invasive surgery appears to have the best outcomes and to be the most acceptable to the patient.
Key words: prolapsed lumbar intervertebral discs, computerized tomographic scans, lumbar spine X-rays, minimally invasive surgery

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ow back pain is reported to occur at some time in

This article draws out the themes and conclusions arising from a systematic review of the published evidence of the effectiveness of the management of PIDs. METHOD A systematic search of the clinical literature was under taken using an initial Medline search on PIDs and asso ciated terms, supplemented by hand searching from se lected articles. A number of key questions to be addressed were identified. These were the benefits of conservative treatment, the investigations that should be used to con firm the nature and level of the lesion, including the role of a plain X-ray, the length of time the patient should be allowed to recover with conservative treatment and the form of intervention which should be offered to patients. Each study was then systematically reviewed using estab lished checklists.56 Greater weight was given to the 12 randomized controlled studies (RCTs) that were located, following the hierarchy of evidence model.6 Such studies are least subject to bias and allow greater confidence over causal inference, however the evidence they provide is of efficacy, rather than effectiveness. The majority of studies identified were lower in the hierarchy of evidence. Among these, those studies that used the following out come criteria were given greater weight: complete ab sence of leg pain, minimal residual back pain and the ability to resume a normal life.

25-50% of the adult population. 1,2 Lumbar disc prolapses are estimated to account for approximately 1 % of cases of back pain) The management of prolapsed lumbar intervertebral discs (PIDs) has changed over time with developments in diagnostic technology (computerized tomographic scans and magnetic resonance imaging), newer minimally invasive surgical approaches and the continued use of complementary therapy. Despite the range of new technologies, no systematic review of the evidence of the effectiveness and appropriateness of different forms of management for PIDs exists in the literature, although a review of spinal disorders in general, published in 1987, does exist.4 Such an overview is essential to enable prac titioners to keep up with current evidence for effective practice. This review was undertaken as a part of a project compar ing current practice in the management of prolapsed lumbar intervertebral discs with the published evidence for effective and appropriate management of this condi tion. The aim was to a establish a knowledge base, pro viding a starting point for the development of clinical

guidelines. An assessment of current clinical practice has been carried out separately.

' ' .'. M. Deane " A.J. Moore , A.F. Long , S. Harrison

The available literature presented a number of problems for the review. Firstly, studies using designs with a greater potential of bias, in particular with non-random alloca tion to treatment and non-blinded assessment had to be drawn on. Secondly, a variety of outcome criteria were

1 Nuffield Institute for Health Services Studies. Leeds. UK 2Atkinson Morley's Hospital. London. UK Correspondence: Meryl Deane, Lecturer & consultant in public health medicine. University of Hull. Cottingham Road. Hull HU6 7RX. UK. tel. +44 1482466027. fax +44 1482441408

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