A systematic review and meta-analysis on surgery for lumbar disc herniation: optimal timing of surgery, return to work and outcomes compared with conservative management.

INTRODUCTION: It has been estimated that between 50 and 90 % of the general population will suffer from low back pain at some point in their lives. 5 %-10 % of this patient population also experiences back-related leg pain caused by underlying spinal pathology such as lumbar disc herniations (LDH). Management options for LDH-related radicular pain include conservative treatment and lumbar disc surgery, the latter of which may be associated with prolonged work absenteeism and substantial socioeconomic consequences. To date, no universal consensus exists regarding the best treatment choice for patients experiencing LDH-related pain. Furthermore no agreement is found regarding the optimal timing of surgery and return to work after surgery leading to the aforementioned societal burden.

AIM: To evaluate the evidence related to the following topics concerning lumbar disc herniations (LDHs): the comparison between surgical and non-surgical management of LDHs, the optimal timing of lumbar disc surgery and the optimal return to work time after surgery.

METHODS: A comprehensive search strategy was used to search Scopus, Web of Science, Embase, Pedro, PubMed, CINAHL (via EBSCO), Cochrane central register of controlled trials (CENTRAL), Clinical Trials Registry Platform (ICTRP) and Clinicaltrials.gov for articles concerning the comparison between surgical and non-surgical management, the optimal timing of surgery and return to work after surgery for LDHs. Grey literature and unpublished data was screened via Google Scholar. Risk of bias and methodological quality were independently assessed by two reviewers using the RoB 2 tool and the ROBINS-I tool by Cochrane. Random-effects meta-analyses were performed for outcomes where sufficient methodological and clinical homogeneity was present.

RESULTS: 15 randomized controlled trials (RCTs), 18 prospective cohort studies (PCS), 8 retrospective cohort studies and 5 hybrid studies were identified providing information concerning our research topics. Meta-analysis of RCTs demonstrated that surgery resulted in better outcomes at short term evaluation in patients suffering from acute sciatica, at long-term (>1 year) follow-up the outcomes of surgery were however comparable with conservative care. Discectomy results in significantly better outcomes than non-surgical techniques developed for treating LDHs. No universal consensus can be found throughout the literature regarding the optimal timing of surgery. Early return to work after surgery for LDHs does not result in inferior outcomes.

CONCLUSION: Surgery leads to a better decrease in leg pain and disability at short-term follow-up when compared with as usual conservative care, at long-term follow-up outcomes after surgery become comparable with conservative care. Discectomy remains to be the gold standard for treating sciatica when compared with non-surgical treatment modalities. Optimal timing of surgery should be determined for each patient individually through a process of shared decision making. There is no evidence suggesting increased risk of reherniation associated with early return to work.