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