Surgical Management of Lumbar Radiculopathy: a Systematic Review
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RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Research Triangle Park, NC, USA; 2RTI International, Research Triangle Park, NC, USA; 3Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
BACKGROUND: Lumbar radiculopathy is characterized by radiating pain with or without motor weakness or sensory disturbances; the point prevalence ranges from 1.6 to 13.4%. The objective of this review was to determine the efficacy, safety, and cost of surgical versus nonsurgical management of symptomatic lumbar radiculopathy in adults. METHODS: We searched PubMed from January 1, 2007, to April 10, 2019 with hand searches of systematic reviews for studies prior to 2007. One reviewer extracted data and a second checked for accuracy. Two reviewers completed independent risk of bias and strength of evidence ratings. RESULTS: We included seven RCTs (N = 1158) and three cost-effectiveness analysis. Surgery reduced leg pain by 6 to 26 points more than nonsurgical interventions as measured on a 0- to 100-point visual analog scale of pain at up to 26 weeks follow-up; differences between groups did not persist at 1 year or later. The evidence was somewhat mixed for function and disability in follow-up through 26 weeks (standardized mean difference [SMD] − 0.16 (95% CI, − 0.30 to − 0.03); minimal differences were observed at 2 years (SMD − 0.06 (95% CI, − 0.20 to 0.07). There were similar improvements in quality of life, neurologic symptoms, and return to work. No surgical deaths occurred and surgical morbidity was infrequent. The incidence of reoperations ranged from 0 to 10%. The average cost per quality-adjusted life year gained from a healthcare payor perspective ranged from $51,156 to $83,322 for surgery compared to nonsurgical interventions. DISCUSSION: Most findings are based on a body of RCT evidence graded as low to very low certainty. Compared with nonsurgical interventions, surgery probably reduces pain and improves function in the short- and mediumterm, but this difference does not persist in the long-term. Although surgery appears to be safe, it may or may not be cost-effective depending on a decision maker’s willingness to pay threshold. KEY WORDS: lumbar radiculopathy; sciatica; discectomy; disc herniation. J Gen Intern Med DOI: 10.1007/s11606-019-05476-8 © Society of General Internal Medicine 2019
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11606-019-05476-8) contains supplementary material, which is available to authorized users. Received June 29, 2019 Revised September 1, 2019 Accepted October 2, 2019
BACKGROUND
Lumbar radiculopathy, also referred to as sciatica, is a syndrome of radiating pain in a lumbar nerve root distribution that may also include motor weakness and sensory disturbances.1 Nerve root compression is typically caused by intervertebral disc herniation or degenerative changes and less commonly by infection, inflammation, neoplasm, vascular disea
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