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The Spine Journal 14 (2014) 2273
Letter to the Editor
Comment on ‘‘An evidence-based clinical
guideline for the diagnosis and treatment of
lumbar disc herniation with
radiculopathy’’
To the Editor:
We read the review on ‘‘An evidence-based clinical
guideline for the diagnosis and treatment of lumbar disc
herniation with radiculopathy’’ by Kreiner at al. [1] with
great interest. We send our kudos to the authors for their
excellent work. Their very practical questions are near to
a spine surgeon’s everyday work. Therefore, the questions
will be fundamental to future discussions. The intention
of this letter is to follow their impulse for discussion.
We would like to focus on the recommendation (Grade
I, ie, insufficient evidence) for or against the performance
of aggressive discectomy or sequestrectomy for the avoidance of chronic low back pain in patients with lumbar disc
herniation with radiculopathy whose symptoms warrant
surgery (Question 24). From the given references, the
conclusions can, in our opinion, hardly be drawn. The discectomy is explicitly described as ‘‘to remove . the
loose intradiscal tissue’’ [2] or ‘‘no attempt was made to
use curettes, and injury to the cartilaginous endplates
has been avoided’’ [3]. In our opinion, this is not a description of ‘‘aggressive discectomy.’’ Moreover, there
might be a bias in the article by Schick and Elhabony
[4], and the follow-up rate in either technique is below
47%; therefore, their results must be interpreted with
caution.
But if aggressive discectomy is done, it can be stated
that there are differences in outcome [3] and reherniation
[5]. Although the level of evidence might be low (number
of patients, historical control group), a trend toward a less
satisfactory overall outcome in more aggressive removal
of remaining intervertebral disc material had been demonstrated, especially during the first year after surgery [6].
1529-9430/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved.
Nevertheless, the main issue is the (low) level of evidence of many studies in the age of evidence-based medicine. As one step toward future comparability and
interpretation of studies, using a clear description of the
surgical technique (sequestrectomy only, limited discectomy, aggressive discectomy, defect size) will be helpful.
We thank our colleagues for a fruitful discussion in
advance.
References
[1] Kreiner DS, Hwang SW, Easa JE, et al. An evidence-based clinical
guideline for the diagnosis and treatment of lumbar disc herniation
with radiculopathy. Spine J 2014;14:180–91.
[2] Barth M, Weiss C, Thome C. Two-year outcome after lumbar microdiscectomy versus microscopic sequestrectomy: part 1: evaluation of
clinical outcome. Spine 2008;33:265–72.
[3] Thome C, Barth M, Scharf J, Schmiedek P. Outcome after lumbar sequestrectomy compared with microdiscectomy: a prospective
randomized study. J Neurosurg Spine 2005;2:271–8.
[4] Schick U, Elhabony R. Prospective comparative study of lumbar sequestrectomy and microdiscectomy. Minim Invasive Neurosurg
2009;52:180–5.
[5] Rogers LA. Experience with limited versus extensive disc removal in
patients undergoing microsurgical operations for ruptured lumbar
discs. Neurosurgery 1988;22:82–5.
[6] Carragee EJ, Spinnickie AO, Alamin TF, Paragioudakis S. A prospective controlled study of limited versus subtotal posterior discectomy:
short-term outcomes in patients with herniated lumbar intervertebral
discs and large posterior annular defect. Spine 2006;31:653–7.
Richard Bostelmann, MD
Hans Jakob Steiger, MD
Department of Neurosurgery
University Hospital of D€
usseldorf
Moorenstrasse 5
40225 D€usseldorf, Germany
FDA device/drug status: Not applicable.
Author disclosures: RB: Nothing to disclose. HJS: Nothing to
disclose.
http://dx.doi.org/10.1016/j.spinee.2014.04.021