Comparison of treatments for lumbar disc herniation Systematic review with network meta-analysis

Study design: Systematic review with network meta-analysis. Objective: To compare patient outcomes of lumbar discectomy with bone-anchored annular closure (LD+ AC), lumbar discectomy (LD), and continuing conservative care (CC) for treatment of lumbar disc herniation refractory to initial conservative management. Summary of background data: Several treatment options are available to patients with refractory symptoms of lumbar disc herniation, but their comparative efficacy is unclear. Methods: A systematic review was performed to compare efficacy of LD+ AC, LD, and CC for treatment of lumbar disc herniation. Outcomes included leg pain, back pain, disability (each reported on a 0-100 scale), reherniation, and reoperation. Data were analyzed using random effects network meta-analysis. Results: This review included 14 comparative studies (8 randomized) involving 3947 patients-11 studies of LD versus CC (3232 patients), 3 studies of LD+ AC versus LD (715 patients), and no studies of LD+ AC versus CC. LD was more effective than CC in reducing leg pain (mean difference [MD] -10, P<.001) and back pain (MD -7, P<. 001). LD+ AC was more effective than LD in reducing risk of reherniation (odds ratio 0.38, P<.001) and reoperation (odds ratio 0.33, P<. 001). There was indirect evidence that LD+ AC was more effective than CC in reducing leg pain (MD -25, P=. 003), back pain (MD -20, P=. 02), and disability (MD -13, P=. 02) although the treatment effect was smaller in randomized trials. Conclusions: Results of a network meta-analysis show LD is more effective than CC in alleviating symptoms of lumbar disc herniation refractory to initial conservative management. Further, LD+ AC lowers risk of reherniation and reoperation versus LD and may improve patient symptoms more than CC.