Review Article

An evidence-based clinical guideline for the diagnosis and treatmentof lumbar disc herniation with radiculopathy

D. Scott Kreiner, MDa,*, Steven W. Hwang, MDb, John E. Easa, MDc, Daniel K. Resnick, MDd,Jamie L. Baisden, MDe, Shay Bess, MDf, Charles H. Cho, MD, MBAg,

Michael J. DePalma, MDh, Paul Dougherty, II, DCi, Robert Fernand, MDj, Gary Ghiselli, MDk,Amgad S. Hanna, MDl, Tim Lamer, MDm, Anthony J. Lisi, DCn, Daniel J. Mazanec, MDo,

Richard J. Meagher, MDp, Robert C. Nucci, MDq, Rakesh D. Patel, MDr,Jonathan N. Sembrano, MDs, Anil K. Sharma, MDt, Jeffrey T. Summers, MDu,Christopher K. Taleghani, MDv, William L. Tontz, Jr., MDw, John F. Toton, MDx

aAhwatukee Sports and Spine, 4530 E. Muirwood Dr, Suite 110, Phoenix, AZ 85048-7693, USA

bDepartment of Neurosurgery, Tufts Medical Center, 800 Washington St, Boston, MA 02111-1552, USAcThe College of Human Medicine, Michigan State University, 12662 Riley St, Suite 120, Holland, MI 49424-8023, USA

dDepartment Neurosurgery, University of Wisconsin Medical School, K4/834 Clinical Science Center, 600 Highland, Madison, WI 53792-0001, USA

eDepartment of Neurosurgery, Medical College of Wisconsin, 9200 W. Wisconsin Ave., Milwaukee, WI 53226-3522, USA

fRocky Mountain Scoliosis and Spine, 2055 High St, Suite 130, Denver, CO 80205-5504, USAgBrigham and Women’s Hospital, 75 Francis St, Boston, MA 02115-6110, USA

h2918 Calcutt Drive, Midlothian, VA 23113-2681, USAi2000 Van Auken Rd, Newark, NY 14513-9221, USAj160 Cheyenne Way, Wayne, NJ 07470-4907, USA

kDenver Spine, 7800 E. Orchard Rd, Suite 100, Greenwood Village, CO 80111-2584, USAl9120 Bear Claw Way, Madison, WI 53717-2734, USA

mMayo Clinic Rochester, 200 1st St SW, Eisenberg 8G, Rochester, MN 55905-0001, USAnVACT Healthcare System, 950 Campbell Ave., Bldg 2, Floor 4, West Haven, CT 06516-2770, USA

oCleveland Clinic Spine Institute, 9500 Euclid Ave., C21, Cleveland, OH 44195-0001, USA

p2152 Susquehanna Rd, Abington, PA 19001-4408, USA

q6322 Gunn Hwy, Tampa, FL 33625-4105, USArUniversity of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5000, USA

sUniversity of Minnesota, 2450 Riverside Ave. S., Suite R200, Minneapolis, MN 55454-1450, USA

tSpine and Pain Medicine, 2 Mockingbird Drive, Colts Neck, NJ 07722-2228, USAuNewSouth NeuroSpine, 2470 Flowood Drive, Flowood, MS 39232-9019, USA

vCumberland Brain and Spine, 3901 Central Pike, Suite 455, Hermitage, TN 37076-3490, USAw3413 Mount Ariane Drive, San Diego, CA 92111-3910, USA

x4866 Hoen Ave., Santa Rosa, CA 95405-7452, USA

Received 7 August 2013; accepted 14 August 2013

Abstract BACKGROUND CONTEXT: The objective of the North American Spine Society’s (NASS) Ev-

idence-Based Clinical Guideline for the Diagnosis and Treatment of Lumbar Disc Herniation with

Radiculopathy is to provide evidence-based recommendations to address key clinical questions sur-

rounding the diagnosis and treatment of lumbar disc herniation with radiculopathy. The guideline is

intended to reflect contemporary treatment concepts for symptomatic lumbar disc herniation with

radiculopathy as reflected in the highest quality clinical literature available on this subject as of July

2011. The goals of the guideline recommendations are to assist in delivering optimum efficacious

treatment and functional recovery from this spinal disorder.

FDA device/drug status: Not applicable.

Author disclosures: Listed at the end of this article.

* Corresponding author. Ahwatukee Sports and Spine, 4530 E. Muir-

wood Dr., Suite 110, Phoenix, AZ 85048-7693, USA. Tel.: (480) 763-

5808.

E-mail address: skreiner@ahwatukeesportsandspine.com (D.S. Kreiner)

1529-9430/$ - see front matter � 2014 Elsevier Inc. All rights reserved.

http://dx.doi.org/10.1016/j.spinee.2013.08.003

The Spine Journal 14 (2014) 180–191

PURPOSE: To provide an evidence-based educational tool to assist spine specialists in the diag-

nosis and treatment of lumbar disc herniation with radiculopathy.

STUDY DESIGN: Systematic review and evidence-based clinical guideline.

METHODS: This guideline is a product of the Lumbar Disc Herniation with Radiculopathy Work

Group of NASS’ Evidence-Based Guideline Development Committee. The work group consisted of

multidisciplinary spine care specialists trained in the principles of evidence-based analysis. A liter-

ature search addressing each question and using a specific search protocol was performed on

English-language references found in Medline, Embase (Drugs and Pharmacology), and four addi-

tional evidence-based databases to identify articles. The relevant literature was then independently

rated using the NASS-adopted standardized levels of evidence. An evidentiary table was created for

each of the questions. Final recommendations to answer each clinical question were developed via

work group discussion, and grades were assigned to the recommendations using standardized

grades of recommendation. In the absence of Level I to IV evidence, work group consensus state-

ments have been developed using a modified nominal group technique, and these statements are

clearly identified as such in the guideline.

RESULTS: Twenty-nine clinical questions were formulated and addressed, and the answers are

summarized in this article. The respective recommendations were graded by strength of the support-

ing literature, which was stratified by levels of evidence.

CONCLUSIONS: The clinical guideline has been created using the techniques of evidence-based

medicine and best available evidence to aid practitioners in the care of patients with symptomatic

lumbar disc herniation with radiculopathy. The entire guideline document, including the evidentiary

tables, suggestions for future research, and all the references, is available electronically on the

NASS Web site at http://www.spine.org/Pages/PracticePolicy/ClinicalCare/ClinicalGuidlines/

Default.aspx and will remain updated on a timely schedule. � 2014 Elsevier Inc. All rights

reserved.

Keywords: Lumbar disc herniation; Radiculopathy; Guideline

Introduction

In an attempt to improve and evaluate the knowledge

base concerning the diagnosis and treatment of lumbar

disc herniation with radiculopathy, the Lumbar Disc

Herniation with Radiculopathy Work Group of the North

American Spine Society’s (NASS) Evidence-Based Clini-

cal Guideline Development Committee developed an

evidence-based clinical guideline on this topic. The Insti-

tute of Medicine has defined a clinical guideline as

‘‘systematically developed statements to assist practitioner

and patient decisions about health care for specific clinical

situations’’ [1].

The application of the principles of evidence-based med-

icine (EBM) to guideline development helps to create an ex-

plicit linkage between the final recommendations in the

guideline and the evidence on which these recommendations

are based [2]. When employing the principles of EBM, the

clinical literature is extensively searched to answer specific

questions about a disease state or medical condition. The lit-

erature that is identified in the search is then rated as to its

scientific merit using levels of evidence, determined by spe-

cific rule sets that apply to human clinical investigations. The

specific questions asked are then answered using studies of

the highest possible levels of evidence that have been ob-

tained from the searches. As a final step, the answers to

the clinical questions are reformulated as recommendations

that are assigned grades of strength related to the best clini-

cal evidence available at the time of answering each

question. The intent of the grade of recommendation is to in-

dicate the strength of the evidence used by the work group in

answering the question asked.

Methods

For this clinical guideline, the guideline development

process was broken down into 11 steps. In Step 1, guideline

participants, trained in the principles of EBM, submitted

a list of clinical questions focused on diagnosis and treat-

ment of lumbar disc herniation with radiculopathy that the

guideline should address. Step 2 consisted of assigning work

group members to a set of clinical questions. Step 3 con-

sisted of each group identifying appropriate search terms

and parameters to direct the literature search according to

the NASS-instituted Literature Search Protocol. The litera-

ture search was then completed in Step 4 by a medical re-

search librarian according to the NASS Literature Search

Protocol and stored in a cross-referencing database for future

use or reference. The following electronic databases were

searched for English-language publications: Medline

(PubMed), ACP Journal Club, Cochrane Database of Sys-

tematic Reviews, Database of Abstracts of Reviews of Effec-

tiveness, Cochrane Central Register of Controlled Trials,

Embase (Drugs and Pharmacology), and Web of Science.

In Step 5, work group members reviewed all the ab-

stracts from the literature search. The best research evi-

dence available was identified and used to answer the

181D.S. Kreiner et al. / The Spine Journal 14 (2014) 180–191

targeted clinical questions. That is, if adequate Level I,

Level II, or Level III studies were available to answer a spe-

cific question, the work group was not required to review

Level IV or Level V evidence. Members independently de-

veloped evidentiary tables summarizing study conclusions,

identifying strengths and weaknesses, and assigning levels

of evidence in Step 6. To systematically control for bias,

at least three work group members reviewed each article se-

lected and independently assigned a level of evidence as

per the NASS levels of evidence table.

In Step 7, work groupmembers participated in webcasts to

update and formulate evidence-based recommendations and

incorporate expert opinion when necessary. Expert physician

opinion was incorporated only where Level I to IV evidence

was insufficient, and thework groups deemed a recommenda-

tion was warranted. For transparency in the incorporation of

consensus, all consensus-based recommendations in this

guideline are clearly stated as such. Voting on guideline rec-

ommendations was conducted using a modification of the

nominal group technique in which each work group member

independently and anonymously ranked a recommendation

on a scale ranging from 1 (‘‘extremely inappropriate’’) to 9

(‘‘extremely appropriate’’) [3]. Consensus was obtained

when at least 80% of work groupmembers ranked the recom-

mendation as 7, 8, or 9. When the 80% threshold was not at-

tained, up to three rounds of discussion and voting were held

to resolve disagreements. If disagreements were not resolved

after these rounds, no recommendation was adopted. When

the recommendations were established, work groupmembers

developed guideline content, referencing the literature that

supported the recommendations.

In Step 8, the completed guideline was submitted to the

NASS Research Council for review and comment. Revi-

sions to recommendations were considered only when sub-

stantiated by a preponderance of appropriate levels of

evidence. Once evidence-based revisions were incorpo-

rated, the guideline was submitted to the NASS Board of

Directors for review and approval in Step 9. In Step 10,

the NASS Board–approved guideline was submitted for in-

clusion in the National Guidelines Clearinghouse. In Step

11, the guideline recommendations will be reviewed every

3 years and the literature base updated by an EBM-trained

multidisciplinary team with revisions to the recommenda-

tions developed in the same manner as in the original

guideline development.

Results

Definition and natural history

Question 1: what is the best working definition of lumbar

disc herniation with radiculopathy?

Localized displacement of disc material beyond the nor-

mal margins of the intervertebral disc space resulting in

pain, weakness, or numbness in a myotomal or dermatomal

distribution.

Work Group Consensus Statement

Question 2: what is the natural history of lumbar disc

herniation with radiculopathy?

In the absence of reliable evidence relating to the natural

history of lumbar disc herniation with radiculopathy, it is the

work group’s opinion thatmost patients will improve indepen-

dent of treatment. Disc herniations will often shrink/regress

over time.Many, but not all, articles have demonstrated a clin-

ical improvement with decreased size of disc herniations.

Work Group Consensus Statement

Diagnosis and imaging

Question 3: what history and physical examination find-

ings are consistent with the diagnosis of lumbar disc herni-

ation with radiculopathy?

Manual muscle testing, sensory testing, supine straight

leg raise, Lasegue sign, and crossed Lasegue sign are rec-

ommended for use in diagnosing lumbar disc herniation

with radiculopathy [4–8].

Grade of recommendation: A

The supine straight leg raise, compared with the seated

straight leg raise, is suggested for use in diagnosing lumbar

disc herniation with radiculopathy [7,9].

Grade of recommendation: B

There is an insufficient evidence to make a recommenda-

tion for or against the use of the cough impulse test, Bell test,

hyperextension test, femoral nerve stretch test, slump test,

lumbar range of motion, or absence of reflexes in diagnosing

lumbar disc herniation with radiculopathy [5,6,8,10–13].

Grade of recommendation: I (insufficient evidence)

Question 4: what are the most appropriate diagnostic

tests (including imaging and electrodiagnostics), and when

are these tests indicated in the evaluation and treatment of

lumbar disc herniation with radiculopathy?

There is a relative paucity of high-quality studies on ad-

vanced imaging in patients with lumbar disc herniation. It

is the opinion of the work group that in patients with history

and physical examination findings consistent with lumbar

disc herniation with radiculopathy, magnetic resonance im-

aging (MRI) be considered as the most appropriate nonin-

vasive test to confirm the presence of lumbar disc

herniation. In patients for whom MRI is either contraindi-

cated or inconclusive, computed tomography (CT) or CT

myelography is the next most appropriate tests to confirm

the presence of lumbar disc herniation.

Work Group Consensus Statement

In patients with history and physical examination findings

consistent with lumbar disc herniation with radiculopathy,

MRI is recommended as an appropriate noninvasive test to

confirm the presence of lumbar disc herniation [14–16].

Grade of recommendation: A

In patients with history and physical examination

findings consistent with lumbar disc herniation with radi-

culopathy, CT scan, myelography, and/or CT myelography

182 D.S. Kreiner et al. / The Spine Journal 14 (2014) 180–191

are recommended as appropriate tests to confirm the pres-

ence of lumbar disc herniation [14,15,17].

Grade of recommendation: A

Electrodiagnostic studies may have utility in diagnosing

nerve root compression although lack the ability to differ-

entiate between lumbar disc herniation and other causes

of nerve root compression. When the diagnosis of lumbar

disc herniation with radiculopathy is suspected, it is the

work group’s opinion that cross-sectional imaging be con-

sidered the diagnostic test of choice and electrodiagnostic

studies should only be used to confirm the presence of co-

morbid conditions.

Work Group Consensus Statement

Somatosensory-evoked potentials are suggested as an

adjunct to cross-sectional imaging to confirm the presence

of nerve root compression but are not specific to the level of

nerve root compression or the diagnosis of lumbar disc her-

niation with radiculopathy [18–20].

Grade of recommendation: B

Electromyography, nerve conduction studies, and F

waves are suggested to have limited utility in the diagnosis

of lumbar disc herniation with radiculopathy. H reflexes can

be helpful in the diagnosis of an S1 radiculopathy, although

are not specific to the diagnosis of lumbar disc herniation

[19,21–24].

Grade of recommendation: B

There is an insufficient evidence to make a recommenda-

tion for or against the use of motor-evoked potentials or ex-

tensor digitorum brevis reflex in the diagnosis of lumbar

disc herniation with radiculopathy [24,25].

Grade of recommendation: I (insufficient evidence)

There is an insufficient evidence to make a recommenda-

tion for or against the use of thermal quantitative sensory

testing or liquid crystal thermography in the diagnosis of

lumbar disc herniation with radiculopathy [26].

Grade of recommendation: I (insufficient evidence)

Outcome measures

Question 5: what are the appropriate outcome measures

for the treatment of lumbar disc herniation with

radiculopathy?

The North American Spine Society has a publication

entitled Compendium of Outcome Instruments for Assess-

ment and Research of Spinal Disorders. To purchase a copy

of the compendium, visit https://webportal.spine.org/

Purchase/ProductDetail.aspx?Product_code568cdd1f4-c4ac-

db11-95b2-001143edb1c1.

For additional information about the compendium,

please contact the NASS Research Department at

nassresearch@spine.org.

Medical/interventional treatment

Question 6: what is the role of pharmacological treat-

ment in the management of lumbar disc herniation with

radiculopathy?

Tumor necrosis factor alpha inhibitors are not suggested

to provide benefit in the treatment of lumbar disc herniation

with radiculopathy [27–29].

Grade of recommendation: B

There is an insufficient evidence to make a recommenda-

tion for or against the use of a single infusion of IV gluco-

corticosteroids in the treatment of lumbar disc herniation

with radiculopathy [30].

Grade of recommendation: I (insufficient evidence)

There is an insufficient evidence to make a recommenda-

tion for or against the use of 5-hydroxytryptamine receptor

inhibitors in the treatment of lumbar disc herniation with

radiculopathy [31].

Grade of recommendation: I (insufficient evidence)

There is an insufficient evidence to make a recommenda-

tion for or against the use of gabapentin in the treatment of

lumbar disc herniation with radiculopathy [32].

Grade of recommendation: I (insufficient evidence)

There is an insufficient evidence to make a recommenda-

tion for or against the use of agmatine sulfate in the treat-

ment of lumbar disc herniation with radiculopathy [33].

Grade of recommendation: I (insufficient evidence)

There is an insufficient evidence to make a recommenda-

tion for or against the use of amitriptyline in the treatment

of lumbar disc herniation with radiculopathy [34].

Grade of recommendation: I (insufficient evidence)

Question 7: what is the role of physical therapy/exercise

in the treatment of lumbar disc herniation with

radiculopathy?

There is an insufficient evidence to make a recommenda-

tion for or against the use of physical therapy/structured ex-

ercise programs as stand-alone treatments for lumbar disc

herniation with radiculopathy [35,36].

Grade of recommendation: I (insufficient evidence)

In the absence of reliable evidence, it is the work group’s

opinion that a limited course of structured exercise is an op-

tion for patients with mild-to-moderate symptoms from

lumbar disc herniation with radiculopathy.

Work Group Consensus Statement

Question 8: what is the role of spinal manipulation in

the treatment of lumbar disc herniation with radiculopathy?

Spinal manipulation is an option for symptomatic relief

in patients with lumbar disc herniation with radiculopathy

[37–39].

Grade of recommendation: C

There is an insufficient evidence to make a recommenda-

tion for or against the use of spinal manipulation compared

with chemonucleolysis in patients with lumbar disc hernia-

tion with radiculopathy [38].

Grade of recommendation: I (insufficient evidence)

Question 9: what is the role of traction (manual or me-

chanical) in the treatment of lumbar disc herniation with

radiculopathy?

183D.S. Kreiner et al. / The Spine Journal 14 (2014) 180–191

There is an insufficient evidence to make a recommenda-

tion for or against the use of traction in the treatment of

lumbar disc herniation with radiculopathy [40].

Grade of recommendation: I (insufficient evidence)

Question 10: what is the role of contrast-enhanced,

fluoroscopic guidance in the routine performance of epidu-

ral steroid injections (ESIs) for the treatment of lumbar disc

herniation with radiculopathy?

Contrast-enhanced fluoroscopy is recommended to

guide ESIs to improve the accuracy of medication delivery

[41–44].

Grade of recommendation: A

Question 11: what is the role of ESI for the treatment of

lumbar disc herniation with radiculopathy?

Transforaminal ESI is recommended to provide short-

term (2–4 weeks) pain relief in a proportion of patients with

lumbar disc herniations with radiculopathy [45–47].

Grade of recommendation: A

Interlaminar ESIs may be considered in the treatment of

patients with lumbar disc herniation with radiculopathy

[48,49].

Grade of recommendation: C

There is an insufficient evidence to make a recommenda-

tion for or against the 12-month efficacy of transforaminal

ESI in the treatment of patients with lumbar disc hernia-

tions with radiculopathy [45,50].

Grade of recommendation: I (insufficient evidence)

Question 12: is there an optimal frequency or quantity of

injections for the treatment of lumbar disc herniations with

radiculopathy?

No evidence to address this question.

Question 13: does the approach (interlaminar, transfor-

aminal, caudal) influence the risks or effectiveness of ESIs

in the treatment of lumbar disc herniations with

radiculopathy?

There is an insufficient evidence to make a recommenda-

tion for or against the effectiveness of one injection approach

over another in the delivery of epidural steroids for patients

with lumbar disc herniation with radiculopathy [49,51,52].

Grade of recommendation: I (insufficient evidence)

Question 14: what is the role of interventional spine pro-

cedures such as intradiscal electrothermal annuloplasty

and percutaneous discectomy (chemical or mechanical) in

the treatment of lumbar disc herniation with radiculopathy?

There is an insufficient evidence to make a recommenda-

tion for or against the use of intradiscal ozone in the treat-

ment of patients with lumbar disc herniation with

radiculopathy [53].

Grade of recommendation: I (insufficient evidence)

Endoscopic percutaneous discectomy may be considered

for the treatment of lumbar disc herniation with radiculop-

athy [54–60].

Grade of recommendation: C

Endoscopic percutaneous discectomy is suggested for

carefully selected patients to reduce early postoperative dis-

ability and reduce opioid use compared with open discec-

tomy in the treatment of patients with lumbar disc

herniation with radiculopathy [57,59,60].

Grade of recommendation: B

Automated percutaneous discectomy may be considered

for the treatment of lumbar disc herniation with radiculop-

athy [61–66].

Grade of recommendation: C

There is an insufficient evidence to make a recommenda-

tion for or against the use of automated percutaneous dis-

cectomy compared with open discectomy in the treatment

of patients with lumbar disc herniation with radiculopathy

[64].

Grade of recommendation: I (insufficient evidence)

There is an insufficient evidence to make a recommenda-

tion for or against the use of plasma disc decompression/

nucleoplasty in the treatment of patients with lumbar disc

herniation with radiculopathy [67,68].

Grade of recommendation: I (insufficient evidence)

There is an insufficient evidence to make a recommenda-

tion for or against the use of plasma disc decompression as

compared with transforaminal ESIs in patients with lumbar

disc herniation who have previously failed transforaminal

ESI therapy [68].

Grade of recommendation: I (insufficient evidence)

There is an insufficient evidence to make a recommenda-

tion for or against the use of intradiscal high-pressure saline

injection in the treatment of patients with lumbar disc her-

niation with radiculopathy [69].

Grade of recommendation: I (insufficient evidence)

There is an insufficient evidence to make a recommen-

dation for or against the use of percutaneous electrother-

mal disc decompression in the treatment of patients with

lumbar disc herniation with radiculopathy [70].

Grade of recommendation: I (insufficient evidence)

Question 15: what is the role of ancillary treatments

such as bracing, electrical stimulation, acupuncture, and

transcutaneous electrical stimulation in the treatment of

lumbar disc herniation with radiculopathy?

There is an insufficient evidence to make a recommenda-

tion for or against the use of ultrasound or low-power laser

in the treatment of lumbar disc herniation with radiculop-

athy [40].

Grade of recommendation: I (insufficient evidence)

Question 16: what is the likelihood that a patient with

lumbar disc herniation with radiculopathy undergoing

medical/interventional treatment would have good/excel-

lent functional outcomes at short (weeks to 6 months),

medium (6 months to 2 years), and long (O2 years)

terms?

184 D.S. Kreiner et al. / The Spine Journal 14 (2014) 180–191

Medical/interventional treatment is suggested to im-

prove functional outcomes in most patients with lumbar

disc herniation with radiculopathy [71–73].

Grade of recommendation: B

Transforaminal ESIs are suggested to improve func-

tional outcomes in most patients with lumbar disc hernia-

tion with radiculopathy [74,75].

Grade of recommendation: B

There is an insufficient evidence to make a recommenda-

tion for or against the use of spinal manipulation to improve

functional outcomes in patients with lumbar disc herniation

with radiculopathy [76].

Grade of recommendation: I (insufficient evidence)

Question 17: are there prognostic factors (eg, age, dura-

tion, or severity of symptoms) that make it more likely that

a patient with lumbar disc herniation with radiculopathy will

have good/excellent functional outcomes at short (weeks to 6

months), medium (6 months to 2 years), and long (O2 years)

terms after medical/interventional treatment?

Patient age (under 40 years of age) and a shorter dura-

tion of symptoms (!3 months) are associated with better

outcomes in patients undergoing percutaneous endoscopic

lumbar discectomy [54,55].

Level of Evidence: II

It is suggested that the type of lumbar disc herniation

does not influence outcomes associated with transforaminal

ESIs in patients with lumbar disc herniation with radiculop-

athy [77,78]

Level of Evidence: II/III

It is suggested that a higher degree of nerve root com-

pression negatively affects outcomes associated with trans-

foraminal ESIs in patients with lumbar disc herniation with

radiculopathy. [77,78].

Level of Evidence: II/III

There is an insufficient evidence to make a recommenda-

tion regarding the influence of patient age on outcomes as-

sociated with medical/interventional treatment for patients

with lumbar disc herniation with radiculopathy [72,78].

Grade of recommendation: I (insufficient evidence)

Question 18: what is the cost-effectiveness of medical/

interventional treatment options in the management of lum-

bar disc herniation with radiculopathy?

The authors concluded that transforaminal ESI is cost-

effective for contained herniations, seemingly by prevent-

ing surgery, which results in savings at 1 year of $12,666

per responder. For extrusions, the treatment seems to be

counter-effective. In this study, there was an increase in sur-

gery for this patient group [46,47].

Surgical treatment

Question 19: are there signs or symptoms associated

with lumbar radiculopathy that predict a favorable surgical

outcome?

It is suggested that patients be assessed preoperatively

for signs of psychological distress, such as somatization

and/or depression, before surgery for lumbar disc hernia-

tion with radiculopathy. Patients with signs of psychologi-

cal distress have worse outcomes than patients without

such signs [79,80].

Grade of recommendation: B

There is an insufficient evidence to make a recommenda-

tion for or against the duration of symptoms before surgery

affecting the prognosis for patients with cauda equina syn-

drome caused by lumbar disc herniation with radiculopathy

[81–84].

Grade of recommendation: I (insufficient evidence)

It is suggested that patients be assessed using the preop-

erative straight leg–raising test before surgery, as the pres-

ence of a positive straight leg raise test correlates with

better outcomes from surgery for lumbar disc herniation

with radiculopathy [80,85].

Grade of recommendation: B

Question 20: what is the role of ESIs or selective nerve

root blocks in diagnosis or patient selection for subsequent

surgical treatment of a lumbar disc herniation with

radiculopathy?

No studies were available to directly address this

question.

Question 21: when is the optimal timing for surgical

intervention?

Surgical intervention before 6 months is suggested in pa-

tients with symptomatic lumbar disc herniation whose

symptoms are severe enough to warrant surgery. Earlier

surgery (within 6 months to 1 year) is associated with faster

recovery and improved long-term outcomes [86–89].

Grade of recommendation: B

There is an insufficient evidence to make a recommenda-

tion for or against urgent surgery for patients with motor

deficits because of lumbar disc herniation with radiculop-

athy [90].

Grade of recommendation: I (insufficient evidence)

Question 22: does discectomy (with or without preoper-

ative medical/interventional treatment) result in better out-

comes (clinical or radiographic) than medical/

interventional treatment for lumbar disc herniation with

radiculopathy?

Discectomy is suggested to provide more effective

symptom relief than medical/interventional care for pa-

tients with lumbar disc herniation with radiculopathy

whose symptoms warrant surgical intervention. In patients

with less severe symptoms, surgery or medical/interven-

tional care appear to be effective for both short- and

long-term relief [73,91–95].

Grade of recommendation: B

In a selected group of patients, automated percutaneous

lumbar discectomy may achieve equivalent results to open

discectomy; however, this equivalence is not felt to be

185D.S. Kreiner et al. / The Spine Journal 14 (2014) 180–191

generalizable to all patients with lumbar disc herniation

with radiculopathy whose symptoms warrant surgery

[57,64,96].

Level of Evidence: II/III

There is an insufficient evidence to make a recommenda-

tion for or against the use of spinal manipulation as an al-

ternative to discectomy in patients with lumbar disc

herniation with radiculopathy whose symptoms warrant

surgery [39].

Grade of recommendation: I (insufficient evidence)

Question 23: are there clinical circumstances in which

lumbar fusion is appropriate in the treatment of lumbar disc

herniation with radiculopathy?

There is an insufficient evidence to make a recommenda-

tion for or against fusion for specific patient populations

with lumbar disc herniation with radiculopathy whose

symptoms warrant surgery [97–100].

Grade of recommendation: I (insufficient evidence)

Question 24: is there a difference in outcome (clinical or

radiographic) or complications between different surgical

approaches in the treatment of a lumbar disc herniation

with radiculopathy?

When surgery is indicated, performance of sequestrec-

tomy or aggressive discectomy is recommended for decom-

pression in patients with lumbar disc herniation with

radiculopathy because there is no difference in rates of re-

herniation [101–103].

Grade of recommendation: B

There is an insufficient evidence to make a recommen-

dation for or against performance of aggressive discec-

tomy or sequestrectomy for the avoidance of chronic

low back pain in patients with lumbar disc herniation

with radiculopathy whose symptoms warrant surgery

[101–103].

Grade of recommendation: I (insufficient evidence)

Use of an operative microscope is suggested to obtain

comparable outcomes to open discectomy for patients with

lumbar disc herniation with radiculopathy whose symptoms

warrant surgery [104,105].

Grade of recommendation: B

There is an insufficient evidence to make a recommen-

dation for or against the use of medial facetectomy to

improve the outcomes for patients with lumbar disc herni-

ation with radiculopathy whose symptoms warrant surgery

[85].

Grade of recommendation: I (insufficient evidence)

There is an insufficient evidence to make a recommenda-

tion for or against the specific surgical approach for far lat-

eral disc herniations in patients with lumbar disc herniation

with radiculopathy whose symptoms warrant surgery

[106,107].

Grade of recommendation: I (insufficient evidence)

There is an insufficient evidence to make a recommenda-

tion for or against the use of tubular discectomy compared

with open discectomy to improve the outcomes for patients

with lumbar disc herniation with radiculopathy whose

symptoms warrant surgery [108].

Grade of recommendation: I (insufficient evidence)

There is an insufficient evidence to make a recommenda-

tion for or against the application of glucocorticoids, with

or without fentanyl, for short-term perioperative pain relief

after decompression for patients with lumbar disc hernia-

tion with radiculopathy whose symptoms warrant surgery

[109,110].

Grade of recommendation: I (insufficient evidence)

The application of glucocorticoids, with or without fen-

tanyl, is not suggested to provide long-term relief of symp-

toms after decompression for patients with lumbar disc

herniation with radiculopathy whose symptoms warrant

surgery [109,110].

Grade of recommendation: B

There is an insufficient evidence to make a recommenda-

tion for or against the application of a fat graft after open

discectomy for patients with lumbar disc herniation with

radiculopathy whose symptoms warrant surgery [111,112].

Grade of recommendation: I (insufficient evidence)

There is an insufficient evidence to make a recommenda-

tion for or against the addition of Oxiplex/SP gel or AD-

CON-L to discectomy for patients with lumbar disc

herniation with radiculopathy whose symptoms warrant

surgery [113–116].

Grade of recommendation: I (insufficient evidence)

Question 25: what are the medium-term (1–4 years) and

long-term (O4 years) results of surgical management of

lumbar disc herniation with radiculopathy?

The performance of surgical decompression is suggested

to provide better medium-term (1–4 years) symptom relief

compared with medical/interventional management of pa-

tients with radiculopathy from lumbar disc herniation

whose symptoms are severe enough to warrant surgery

[89,91–94].

Grade of recommendation: B

Surgical decompression provides long-term (O4 years)

symptom relief for patients with radiculopathy from lumbar

disc herniation whose symptoms warrant surgery. It should

be noted that a substantial portion (23%–28%) of patients

will have chronic back or leg pain [117–122].

Level of Evidence: IV

Question 26: is there a difference in outcome or compli-

cations between different sites of service for the surgical

management of a lumbar disc herniation with

radiculopathy?

No studies were available to address this question.

Value of spine care

Question 27: what is the cost-effectiveness of surgical

treatment options in the management of lumbar disc herni-

ation with radiculopathy?

186 D.S. Kreiner et al. / The Spine Journal 14 (2014) 180–191

The cost-effectiveness of microdiscectomy for lumbar

disc herniation has been evaluated by several authors using

different methodologies and from different perspectives

(patient, payer, society). Overall, the committee felt that

there was strong and consistent evidence supporting the

cost-effectiveness of microdiscectomy for patients with

symptomatic lumbar disc herniation who desired surgical

treatment. Although criteria for judging the methodological

quality of cost-effectiveness studies have been suggested,

the committee had great difficulty in applying these criteria

to the available literature regarding lumbar disc herniation.

This difficulty was a result of a combination of factors in-

cluding the relative immaturity of the rating methodology,

the relative inexperience of the committee members in eval-

uating cost-effectiveness studies, and the different method-

ologies employed by the authors of the primary studies

[123–125].

Question 28: does the surgical approach for lumbar disc

herniation with radiculopathy have an effect on the value of

treatment?

No studies were available to address this question.

Question 29: does the site-of-service chosen for surgical

management of lumbar disc herniation with radiculopathy

affect the value of treatment?

No studies were available to address this question.

Discussion

This evidence-based clinical guideline for the diagnosis

and treatment of lumbar disc herniation with radiculopathy

has several functions. It is an educational tool for both cli-

nicians and patients, and as such, this particular guideline is

intended to assist practitioners who treat patients with lum-

bar disc herniation with radiculopathy. This guideline also

serves to focus and rate the clinical data on this topic. An

evidence-based guideline such as this allows a physician

access to the best and most current evidence and reduces

the burden of ‘‘keeping up with the literature’’ that spans

innumerable journals from a broad spectrum of disciplines.

In addition, this evidence-based clinical guideline has the

potential to improve the appropriateness and effectiveness

of patient care by basing decisions on the best evidence

available.

Finally, the creation of this guideline serves to identify

knowledge gaps in the clinical literature on lumbar disc

herniation with radiculopathy. High-quality clinical guide-

lines ideally identify and suggest future research topics

to improve guideline development and thus patient

care, as detailed in the current guideline. The complete

clinical guideline summarized in this article along with ex-

tensive descriptive narratives on each topic outlining the

evidence and the work group rationale for the answers to

each question can be found on the NASS Web site

at http://www.spine.org/Pages/PracticePolicy/ClinicalCare/

ClinicalGuidlines/Default.aspx. In addition, more extensive

descriptions are provided for the guideline development

process used at NASS, along with all the references used

in this guideline and suggestions for future research studies

on delivering optimum efficacious treatment and functional

recovery from this spinal disorder.

Author disclosures:

DSK: Nothing to disclose. SWH: Nothing to disclose.

JEE: Stock Ownership: Janus Biotherapeutics (E, Paid di-

rectly to institution). DKR: Board of Directors: NASS

Board of Directors (Research Council Director) (None),

Congress of Neurological Surgeons President Elect (None);

Scientific Advisory Board/Other Office: Neurosurgical Re-

search Foundation (None); Grants: AANS Spine Section

Grant (D, Paid directly to institution/employer). JLB: Sup-

port for travel to meetings for the study or other purposes:

NASS (A). SB: Royalties: Pioneer (B); Consulting: DePuy

Spine (B), Medtronic (B), Lanyx (B), Alphatec (B), Allo-

source (B); Speaking and/or Teaching Arrangements:

Medtronic (B); Scientific Advisory Board/Other Office: Al-

losource (B); Grants: DePuy Spine (B). CHC: Board of Di-

rectors: American Society of Spine Radiology (Executive

Committee [March 2012 to February 2013], None). MJD:

Consulting: Vertiflex (Financial, Hourly consultant, Paid di-

rectly to institution/employer); Board of Directors: ISIS

(travel reimbursement, Paid directly to institution/em-

ployer), Virginia Spine Research Institute, Inc. (Salaried

position as President; Director of Research, Paid directly

to institution/employer); Scientific Advisory Board/Other

Office: Research Committee Vice-Chair, International

Spine Intervention Society (None); Research Support (In-

vestigator Salary): Spinal Restoration, Inc. (B, Paid directly

to institution/employer), Mesoblast, Inc. (B, Paid directly to

institution/employer); Grants: Spinal Restoration, Inc. (D,

Paid directly to institution/employer), Mesoblast, Inc. (D,

Paid directly to institution/employer), St. Jude Medical

(C, Paid directly to institution/employer); Relationships

Outside the One Year Requirement: AOI Medical (Upcom-

ing Committee Meeting[Clinical Guidelines; Nominating],

03/2010, Consulting, 0), Stryker Interventional Spine

(NASS Annual Meeting, 03/2010, Consulting, B), St. Jude

Medical (NASS Annual Meeting, 03/2010, Consulting),

Stryker Biotech (NASS Annual Meeting, 6/2011, Grant,

0), ATRM (NASS Annual Meeting, 6/2011, Grant, 0).

PD: Nothing to disclose. RF: Nothing to disclose. GG:

Royalties: Zimmer Spine (D); Stock Ownership: Mesoblast

(B); Private Investments: DiFusion (E); Consulting: Biomet

(B); Scientific Advisory Board/Other Office: DiFusion

(None/Stock options in company). ASH: Trips/Travel:

Medtronic (None). TL: Nothing to disclose. AJL: Grants:

NCMIC Foundation (F, Paid directly to institution). DJM:

Nothing to disclose. RJM: Nothing to disclose. RCN:

Nothing to disclose. RDP: Consulting: Globus (B), Stryker

(B); Speaking and/or Teaching Arrangements: Globus (B),

187D.S. Kreiner et al. / The Spine Journal 14 (2014) 180–191

Stryker (B). JNS: Board of Directors: Society of Lateral

Access Surgeons (None), Philippine Minnesota Medical

Association (None), University of the Philippines Alumni

of Minnesota (None); Research Support (Investigator Sal-

ary, Staff/Materials): NuVasive (None, Paid directly to in-

stitution/employer). AKS: Nothing to disclose. JTS:

Private Investments: Morris Innovative (2000 shares), Med-

iWorkx (15% ownership interest); Board of Directors:

First-Choice Insurance (None/Term ended June 2012), In-

ternational Spine Intervention Society (None, travel reim-

bursement, Board of Directors and Vice President). CKT:

Royalties: Seaspine (D), Globus (!A); Consulting: Seas-

pine (B), Theken (C); Speaking and/or Teaching Arrange-

ments: Globus (B). WLT: Stock Ownership: Phygen (6%,

Paid directly to institution/employer); Board of Directors:

Board of Managers 2009–2010 (B). JFT: Nothing to

disclose.

The disclosure key can be found on the Table of Con-

tents and at www.TheSpineJournalOnline.com.

References

[1] Crossing the quality chasm: a new health system for the 21st cen-

tury. Washington, DC: Institute of Medicine, 2001.

[2] Heffner JE. Does evidence-based medicine help the development of

clinical practice guidelines? Chest 1988;113(3 Suppl):172S–8S.

[3] Murphy MK, Black LA, Lamping DL, et al. Consensus develop-

ment methods, and their use in clinical guideline development.

Health Technol Assessment 1998;2:1–88.

[4] Jensen OH. The level-diagnosis of a lower lumbar disc herniation:

the value of sensibility and motor testing. Clin Rheumatol 1987;6:

564–9.

[5] Kortelainen P, Puranen J, Koivisto E, et al. Symptoms and signs of

sciatica and their relation to the localization of the lumbar disc her-

niation. Spine 1985;10:88–92.

[6] Poiraudeau S, Foltz V, Drape JL, et al. Value of the bell test and the

hyperextension test for diagnosis in sciatica associated with disc

herniation: comparison with Lasegue’s sign and the crossed La-

segue’s sign. Rheumatology (Oxford) 2001;40:460–6.

[7] Rabin A, Gerszten PC, Karausky P, et al. The sensitivity of the

seated straight-leg raise test compared with the supine straight-leg

raise test in patients presenting with magnetic resonance imaging

evidence of lumbar nerve root compression. Arch Phys Med Rehabil

2007;88:840–3.

[8] Vucetic N, Svensson O. Physical signs in lumbar disc hernia. Clin

Orthop Relat Res 1996;333:192–201.

[9] Summers B, Mishra V, Jones JM. The flip test: a reappraisal. Spine

2009;34:1585–9.

[10] Christodoulides AN. Ipsilateral sciatica on femoral nerve stretch test

is pathognomonic of an L4/5 disc protrusion. J Bone Joint Surg Br

1989;71:88–9.

[11] Majlesi J, Togay H, Unalan H, et al. The sensitivity and specificity

of the Slump and the Straight Leg Raising tests in patients with lum-

bar disc herniation. J Clin Rheumatol 2008;14:87–91.

[12] Albeck MJ. A critical assessment of clinical diagnosis of disc her-

niation in patients with monoradicular sciatica. Acta Neurochir

1996;138:40–4.

[13] Jonsson B, Stromqvist B. Symptoms and signs in degeneration of

the lumbar spine. A prospective, consecutive study of 300 operated

patients. J Bone Joint Surg Br 1993;75:381–5.

[14] Jackson RP, Cain JE Jr, Jacobs RR, et al. The neuroradiographic di-

agnosis of lumbar herniated nucleus pulposus: II. A comparison of

computed tomography (CT), myelography, CT-myelography, and

magnetic resonance imaging. Spine 1989;14:1362–7.

[15] Janssen ME, Bertrand SL, Joe C, et al. Lumbar herniated disk dis-

ease: comparison of MRI, myelography, and post-myelographic CT

scan with surgical findings. Orthopedics 1994;17:121–7.

[16] Pfirrmann CW, Dora C, Schmid MR, et al. MR image-based grading

of lumbar nerve root compromise due to disk herniation: reliability

study with surgical correlation. Radiology 2004;230:583–8.

[17] Fries JW, Abodeely DA, Vijungco JG, et al. Computed tomography

of herniated and extruded nucleus pulposus. J Comput Assist To-

mogr 1982;6:874–87.

[18] Pape E, Eldevik OP, Vandvik B. Diagnostic validity of somatosen-

sory evoked potentials in sub-groups of patients with sciatica. Eur

Spine J 2002;11:38–46.

[19] Beyaz EA, Akyuz G, Us O. The role of somatosensory evoked po-

tentials in the diagnosis of lumbosacral radiculopathies. Electro-

myogr Clin Neurophysiol 2009;49:131–42.

[20] Dumitru D, Dreyfuss P. Dermatomal/segmental somatosensory

evoked potential evaluation of L5/S1 unilateral/unilevel radiculopa-

thies. Muscle Nerve 1996;19:442–9.

[21] Albeck MJ, Taher G, Lauritzen M, et al. Diagnostic value of elec-

trophysiological tests in patients with sciatica. Acta Neurol Scand

2000;101:249–54.

[22] Tullberg T, Svanborg E, Isacsson J, et al. A preoperative and post-

operative study of the accuracy and value of electrodiagnosis in pa-

tients with lumbosacral disc herniation. Spine 1993;18:837–42.

[23] Dillingham TR, Dasher KJ. The lumbosacral electromyographic

screen: revisiting a classic paper. Clin Neurophysiol 2000;111:

2219–22.

[24] Marin R, Dillingham TR, Chang A, et al. Extensor digitorum brevis

reflex in normals and patients with radiculopathies. Muscle Nerve

1995;18:52–9.

[25] Tabaraud F, Hugon J, Chazot F, et al. Motor evoked responses after

lumbar spinal stimulation in patients with L5 or S1 radicular in-

volvement. Electroencephalogr Clin Neurophysiol 1989;72:334–9.

[26] Samuelsson L, Lundin A. Thermal quantitative sensory testing in

lumbar disc herniation. Eur Spine J 2002;11:71–5.

[27] Genevay S, Viatte S, Finckh A, et al. Adalimumab in severe and

acute sciatica: a multicenter, randomized, double-blind, placebo-

controlled trial. Arthritis Rheum 2010;62:2339–46.

[28] Korhonen T, Karppinen J, Paimela L, et al. The treatment of disc

herniation-induced sciatica with infliximab: results of a randomized,

controlled, 3-month follow-up study. Spine 2005;30:2724–8.

[29] Korhonen T, Karppinen J, Paimela L, et al. The treatment of disc-

herniation-induced sciatica with infliximab: one-year follow-up re-

sults of FIRST II, a randomized controlled trial. Spine 2006;31:

2759–66.

[30] Finckh A, Zufferey P, Schurch MA, et al. Short-term efficacy of

intravenous pulse glucocorticoids in acute discogenic sciatica. A

randomized controlled trial. Spine 2006;31:377–81.

[31] Kanayama M, Hashimoto T, Shigenobu K, et al. New treatment of

lumbar disc herniation involving 5-hydroxytryptamine2A receptor

inhibitor: a randomized controlled trial. J Neurosurg Spine 2005;2:

441–6.

[32] Kasimcan O, Kaptan H. Efficacy of gabapentin for radiculopathy

caused by lumbar spinal stenosis and lumbar disk hernia. Neurol

Med Chir (Tokyo) 2010;50:1070–3.

[33] Keynan O, Mirovsky Y, Dekel S, et al. Safety and efficacy of dietary

agmatine sulfate in lumbar disc-associated radiculopathy. An open-

label, dose-escalating study followed by a randomized, double-

blind, placebo-controlled trial. Pain Med 2010;11:356–68.

[34] Pirbudak L, Karakurum G, Oner U, et al. Epidural corticosteroid in-

jection and amitriptyline for the treatment of chronic low back pain

associated with radiculopathy. Pain Clinic 2003;15:247–53.

[35] Bakhtiary AH, Safavi-Farokhi Z, Rezasoltani A. Lumbar stabilizing

exercises improve activities of daily living in patients with lumbar

disc herniation. J Back Musculoskelet Rehabil 2005;18:55–60.

188 D.S. Kreiner et al. / The Spine Journal 14 (2014) 180–191

[36] Thackeray A, Fritz JM, Brennan GP, et al. A pilot study examining

the effectiveness of physical therapy as an adjunct to selective nerve

root block in the treatment of lumbar radicular pain from disk her-

niation: a randomized controlled trial. Phys Ther 2010;90:1717–29.

[37] Santilli V, Beghi E, Finucci S. Chiropractic manipulation in the

treatment of acute back pain and sciatica with disc protrusion: a ran-

domized double-blind clinical trial of active and simulated spinal

manipulations. Spine J 2006;6:131–7.

[38] Burton AK, Tillotson KM, Cleary J. Single-blind randomised con-

trolled trial of chemonucleolysis and manipulation in the treatment

of symptomatic lumbar disc herniation. Eur Spine J 2000;9:202–7.

[39] McMorland G, Suter E, Casha S, et al. Manipulation or microdis-

kectomy for sciatica? A prospective randomized clinical study. J

Manipulative Physiol Ther 2010;33:576–84.

[40] Unlu Z, Tascl S, Tarhan S, et al. Comparison of 3 physical therapy

modalities for acute pain in lumbar disc herniation measured by

clinical evaluation and magnetic resonance imaging. J Manipulative

Physiol Ther 2008;31:191–8.

[41] Renfrew DL, Moore TE, Kathol MH, et al. Correct placement of

epidural steroid injections: fluoroscopic guidance and contrast ad-

ministration. AJNR Am J Neuroradiol 1991;12:1003–7.

[42] Stitz M, Sommer H. Accuracy of blind versus fluoroscopically

guided caudal epidural injections. Spine 1999;24:1371–6.

[43] White AH, Derby R, Wynne G. Epidural injections for the diagnosis

and treatment of low back pain. Spine 1980;5:78–86.

[44] Mehta M, Salmon N. Extradural block: confirmation of the injection

site by x-ray monitoring. Anaesthesia 1985;40:1009–12.

[45] Ghahreman A, Ferch R, Bogduk N. The efficacy of transforaminal

injection of steroids for the treatment of lumbar radicular pain. Pain

Med 2010;11:1149–68.

[46] Karppinen J, Malmivaara A, Kurunlahti M, et al. Periradicular infil-

tration for sciatica: a randomized controlled trial. Spine 2001;26:

1059–67.

[47] Karppinen J, Ohinmaa A, Malmivaara A, et al. Cost effectiveness of

periradicular infiltration for sciatica: subgroup analysis of a random-

ized controlled trial. Spine 2001;26:2587–95.

[48] Manchikanti L, Singh V, Falco FJ, et al. Evaluation of the effective-

ness of lumbar interlaminar epidural injections in managing chronic

pain of lumbar disc herniation or radiculitis: a randomized, double-

blind, controlled trial. Pain Physician 2010;13:343–55.

[49] Ackerman WE, Ahmad M. The efficacy of lumbar epidural steroid

injections in patients with lumbar disc herniations. Anesth Analg

2007;104:1217–22.

[50] Vad VB, Bhat AL, Lutz GE, et al. Transforaminal epidural steroid

injections in lumbosacral radiculopathy: a prospective randomized

study. Spine 2002;27:11–6.

[51] Kolsi I, Delecrin J, Berthelot JM, et al. Efficacy of nerve root versus

interspinous injections of glucocorticoids in the treatment of disk-

related sciatica. A pilot, prospective, randomized, double-blind

study. Joint Bone Spine 2000;67:113–8.

[52] Schaufele MK, Hatch L, Jones W. Interlaminar versus transforami-

nal epidural injections for the treatment of symptomatic lumbar in-

tervertebral disc herniations. Pain Physician 2006;9:361–6.

[53] Gallucci M, Limbucci N, Zugaro L, et al. Sciatica: treatment with

intradiscal and intraforaminal injections of steroid and oxygen-

ozone versus steroid only. Radiology 2007;242:907–13.

[54] Ahn Y, Lee SH, Lee JH, et al. Transforaminal percutaneous endo-

scopic lumbar discectomy for upper lumbar disc herniation: clinical

outcome, prognostic factors, and technical consideration. Acta Neu-

rochir (Wien) 2009;151:199–206.

[55] AhnY, Lee SH, ParkWM, et al. Percutaneous endoscopic lumbar dis-

cectomy for recurrent disc herniation: surgical technique, outcome,

and prognostic factors of 43 consecutive cases. Spine 2004;29:

E326–32.

[56] Cervellini P, De Luca GP, Mazzetto M, et al. Micro-endoscopic-dis-

cectomy (MED) for far lateral disc herniation in the lumbar spine.

Technical note. Acta Neurochir Suppl 2005;92:99–101.

[57] Hermantin FU, Peters T, Quartararo L, et al. A prospective, random-

ized study comparing the results of open discectomy with those of

video-assisted arthroscopic microdiscectomy. J Bone Joint Surg

Am 1999;81:958–65.

[58] Jang JS, An SH, Lee SH. Transforaminal percutaneous endoscopic

discectomy in the treatment of foraminal and extraforaminal lumbar

disc herniations. J Spinal Disord Tech 2006;19:338–43.

[59] Mayer HM, Brock M. Percutaneous endoscopic discectomy: surgi-

cal technique and preliminary results compared to microsurgical

discectomy. J Neurosurg 1993;78:216–25.

[60] Ruetten S, Komp M, Merk H, et al. Full-endoscopic interlaminar

and transforaminal lumbar discectomy versus conventional micro-

surgical technique: a prospective, randomized, controlled study.

Spine 2008;33:931–9.

[61] Alo KM, Wright RE, Sutcliffe J, et al. Percutaneous lumbar discec-

tomy: clinical response in an initial cohort of fifty consecutive

patients with chronic radicular pain. Pain Pract 2004;4:19–29.

[62] Davis GW, Onik G, Helms C. Automated percutaneous discectomy.

Spine 1991;16:359–63.

[63] Faubert C, Caspar W. Lumbar percutaneous discectomy. Initial ex-

perience in 28 cases. Neuroradiology 1991;33:407–10.

[64] Haines SJ, Jordan N, Boen JR, et al. Discectomy strategies for lum-

bar disc herniation: results of the LAPDOG trial. J Clin Neurosci

2002;9:411–7.

[65] Lierz P, Alo KM, Felleiter P. Percutaneous lumbar discectomy using

the Dekompressor system under CT-control. Pain Pract 2009;9:

216–20.

[66] Revel M, Payan C, Vallee C, et al. Automated percutaneous lumbar

discectomy versus chemonucleolysis in the treatment of sciatica. A

randomized multicenter trial. Spine 1993;18:1–7.

[67] Cohen SP, Williams S, Kurihara C, et al. Nucleoplasty with or with-

out intradiscal electrothermal therapy (IDET) as a treatment for

lumbar herniated disc. J Spinal Disord Tech 2005;(18 Suppl):

S119–24.

[68] Gerszten PC, Smuck M, Rathmell JP, et al. Plasma disc decompres-

sion compared with fluoroscopy-guided transforaminal epidural ste-

roid injections for symptomatic contained lumbar disc herniation:

a prospective, randomized, controlled trial. J Neurosurg Spine

2010;12:357–71.

[69] Kanai A. Treatment of lumbar disk herniation by percutaneous

intradiscal high-pressure injection of saline. Pain Med 2009;10:

76–84.

[70] Schaufele MK. Single level lumbar disc herniations resulting in ra-

dicular pain: pain and functional outcomes after treatment with tar-

geted disc decompression. Pain Med 2008;9:835–43.

[71] Saal JA, Saal JS. Nonoperative treatment of herniated lumbar inter-

vertebral disc with radiculopathy. An outcome study. Spine 1989;14:

431–7.

[72] Suri P, Hunter DJ, Jouve C, et al. Nonsurgical treatment of lumbar

disk herniation: are outcomes different in older adults? J Am Geriatr

Soc 2011;59:423–9.

[73] Thomas KC, Fisher CG, Boyd M, et al. Outcome evaluation of sur-

gical and nonsurgical management of lumbar disc protrusion caus-

ing radiculopathy. Spine 2007;32:1414–22.

[74] Ng L, Chaudhary N, Sell P. The efficacy of corticosteroids in peri-

radicular infiltration for chronic radicular pain: a randomized,

double-blind, controlled trial. Spine 2005;30:857–62.

[75] Lutz GE, Vad VB, Wisneski RJ. Fluoroscopic transforaminal lum-

bar epidural steroids: an outcome study. Arch Phys Med Rehabil

1998;79:1362–6.

[76] Murphy DR, Hurwitz EL, McGovern EE. A nonsurgical approach to

the management of patients with lumbar radiculopathy secondary to

herniated disk: a prospective observational cohort study with fol-

low-up. J Manipulative Physiol Ther 2009;32:723–33.

[77] Ghahreman A, Bogduk N. Predictors of a favorable response to

transforaminal injection of steroids in patients with lumbar radicular

pain due to disc herniation. Pain Med 2011;12:871–9.

189D.S. Kreiner et al. / The Spine Journal 14 (2014) 180–191

[78] Choi SJ, Song JS, Kim C, et al. The use of magnetic resonance

imaging to predict the clinical outcome of non-surgical treatment

for lumbar interverterbal disc herniation. Korean J Radiol 2007;8:

156–63.

[79] Chaichana KL, Mukherjee D, Adogwa O, et al. Correlation

of preoperative depression and somatic perception scales with post-

operative disability and quality of life after lumbar discectomy.

J Neurosurg Spine 2011;14:261–7.

[80] Kohlboeck G, Greimel KV, Piotrowski WP, et al. Prognosis of mul-

tifactorial outcome in lumbar discectomy—a prospective longitudi-

nal study investigating patients with disc prolapse. Clin J Pain

2004;20:455–61.

[81] Ahn UM, Ahn NU, Buchowski JM, et al. Cauda equina syndrome

secondary to lumbar disc herniation: a meta-analysis of surgical out-

comes. Spine 2000;25:1515–22.

[82] Buchner M, Schiltenwolf M. Cauda equina syndrome caused by in-

tervertebral lumbar disk prolapse: mid-term results of 22 patients

and literature review. Orthopedics 2002;25:727–31.

[83] McCarthy MJ, Aylott CE, Grevitt MP, et al. Cauda equina syn-

drome: factors affecting long-term functional and sphincteric out-

come. Spine 2007;32:207–16.

[84] Olivero WC, Wang H, Hanigan WC, et al. Cauda equina syndrome

(CES) from lumbar disc herniations. J Spinal Disord Tech 2009;22:

202–6.

[85] Abramovitz JN, Neff SR. Lumbar disc surgery: results of the pro-

spective lumbar discectomy study of the Joint Section on Disorders

of the Spine and Peripheral Nerves of the American Association of

Neurological Surgeons and the Congress of Neurological Surgeons.

Neurosurgery 1991;29:301–7; discussion 307–8.

[86] Fisher C, Noonan V, Bishop P, et al. Outcome evaluation of the op-

erative management of lumbar disc herniation causing sciatica. J

Neurosurg 2004;100(4 Suppl Spine):317–24.

[87] Ng LC, Sell P. Predictive value of the duration of sciatica for lumbar

discectomy. A prospective cohort study. J Bone Joint Surg Br

2004;86:546–9.

[88] Nygaard OP, Kloster R, Solberg T. Duration of leg pain as a predic-

tor of outcome after surgery for lumbar disc herniation: a prospective

cohort study with 1-year follow up. J Neurosurg 2000;92(2 Suppl):

131–4.

[89] Peul WC, van Houwelingen HC, van den Hout WB, et al. Surgery

versus prolonged conservative treatment for sciatica. N Engl J

Med 2007;356:2245–56.

[90] Ghahreman A, Ferch RD, Rao P, et al. Recovery of ankle dorsiflex-

ion weakness following lumbar decompressive surgery. J Clin Neu-

rosci 2009;16:1024–7.

[91] Buttermann GR. Treatment of lumbar disc herniation: epidural ste-

roid injection compared with discectomy—a prospective, random-

ized study. J Bone Joint Surg Am 2004;86A:670–9.

[92] Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs nonopera-

tive treatment for lumbar disk herniation: the Spine Patient Out-

comes Research Trial (SPORT) observational cohort. JAMA

2006;296:2451–9.

[93] Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus nonop-

erative treatment for lumbar disc herniation: four-year results for the

Spine Patient Outcomes Research Trial (SPORT). Spine 2008;33:

2789–800.

[94] Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonopera-

tive treatment for lumbar disk herniation: the Spine Patient Out-

comes Research Trial (SPORT): a randomized trial. JAMA

2006;296:2441–50.

[95] Osterman H, Seitsalo S, Karppinen J, et al. Effectiveness of micro-

discectomy for lumbar disc herniation—a randomized controlled

trial with 2 years of follow-up. Spine 2006;31:2409–14.

[96] van Alphen HA, Braakman R, Berfelo MW, et al. Chemonucleolysis

or discectomy? Results of a randomized multicentre trial in patients

with a herniated lumbar intervertebral disc (a preliminary report).

Acta Neurochir Suppl 1988;43:35–8.

[97] Takeshima T, Kambara K, Miyata S, et al. Clinical and radiographic

evaluation of disc excision for lumbar disc herniation with and with-

out posterolateral fusion. Spine 2000;25:450–6.

[98] Donceel P, Du Bois M. Fitness for work after surgery for lum-

bar disc herniation: a retrospective study. Eur Spine J 1998;7:

29–35.

[99] Eie N. Comparison of the results in patients operated upon for rup-

tured lumbar discs with and without spinal fusion. Acta Neurochir

(Wien) 1978;41:107–13.

[100] Matsunaga S, Sakou T, Taketomi E, et al. Comparison of operative

results of lumbar disc herniation in manual laborers and athletes.

Spine 1993;18:2222–6.

[101] Barth M, Weiss C, Thome C. Two-year outcome after lumbar micro-

discectomy versus microscopic sequestrectomy: part 1: evaluation

of clinical outcome. Spine 2008;33:265–72.

[102] Thome C, Barth M, Scharf J, et al. Outcome after lumbar seques-

trectomy compared with microdiscectomy: a prospective random-

ized study. J Neurosurg Spine 2005;2:271–8.

[103] Schick U, Elhabony R. Prospective comparative study of lumbar se-

questrectomy and microdiscectomy. Minim Invasive Neurosurg

2009;52:180–5.

[104] Henriksen L, Schmidt K, Eskesen V, et al. A controlled study of mi-

crosurgical versus standard lumbar discectomy. Br J Neurosurg

1996;10:289–93.

[105] Tureyen K. One-level one-sided lumbar disc surgery with and with-

out microscopic assistance: 1-year outcome in 114 consecutive pa-

tients. J Neurosurg 2003;99:247–50.

[106] Epstein NE. Evaluation of varied surgical approaches used in the

management of 170 far-lateral lumbar disc herniations: indications

and results. J Neurosurg 1995;83:648–56.

[107] Ryang YM, Rohde I, Ince A, et al. Lateral transmuscular or com-

bined interlaminar/paraisthmic approach to lateral lumbar disc her-

niation? A comparative clinical series of 48 patients. J Neurol

Neurosurg Psychiatry 2005;76:971–6.

[108] Arts MP, Brand R, van den Akker ME, et al. Tubular diskectomy vs

conventional microdiskectomy for sciatica: a randomized controlled

trial. JAMA 2009;302:149–58.

[109] Debi R, Halperin N, Mirovsky Y. Local application of steroids

following lumbar discectomy. J Spinal Disord Tech 2002;15:273–6.

[110] Masopust V, Haeckel M, Netuka D, et al. Postoperative epidural

fibrosis. Clin J Pain 2009;25:600–6.

[111] Jensen TT, Asmussen K, Berg-Hansen EM, et al. First-time opera-

tion for lumbar disc herniation with or without free fat transplanta-

tion. Prospective triple-blind randomized study with reference to

clinical factors and enhanced computed tomographic scan 1 year af-

ter operation. Spine 1996;21:1072–6.

[112] Gambardella G, Gervasio O, Zaccone C, et al. Prevention of recur-

rent radicular pain after lumbar disc surgery: a prospective study.

Acta Neurochir Suppl 2005;92:151–4.

[113] Kim KD, Wang JC, Robertson DP, et al. Reduction of radiculopathy

and pain with Oxiplex/SP gel after laminectomy, laminotomy, and

discectomy: a pilot clinical study. Spine 2003;28:1080–7; discussion

1087–8.

[114] Kim KD, Wang JC, Robertson DP, et al. Reduction of leg pain and

lower-extremity weakness for 1 year with Oxiplex/SP gel following

laminectomy, laminotomy, and discectomy. Neurosurg Focus

2004;17:ECP1.

[115] Ronnberg K, Lind B, Zoega B, et al. Peridural scar and its re-

lation to clinical outcome: a randomised study on surgically

treated lumbar disc herniation patients. Eur Spine J 2008;17:

1714–20.

[116] Petrie JL, Ross JS. Use of ADCON-L to inhibit postoperative peri-

dural fibrosis and related symptoms following lumbar disc surgery:

a preliminary report. Eur Spine J 1996;(Suppl 1):S10–7.

[117] Bakhsh A. Long-term outcome of lumbar disc surgery: an experi-

ence from Pakistan Clinical article. J Neurosurg Spine 2010;12:

666–70.

190 D.S. Kreiner et al. / The Spine Journal 14 (2014) 180–191

[118] Findlay GF, Hall BI, Musa BS, et al. A 10-year follow-up of

the outcome of lumbar microdiscectomy. Spine 1998;23:

1168–71.

[119] Loupasis GA, Stamos K, Katonis PG, et al. Seven- to 20-year out-

come of lumbar discectomy. Spine 1999;24:2313–7.

[120] Padua R, Padua S, Romanini E, et al. Ten- to 15-year outcome of

surgery for lumbar disc herniation: radiographic instability and clin-

ical findings. Eur Spine J 1999;8:70–4.

[121] Porchet F, Chollet-Bornand A, de Tribolet N. Long-term follow up

of patients surgically treated by the far-lateral approach for foram-

inal and extraforaminal lumbar disc herniations. J Neurosurg

1999;90(1 Suppl):59–66.

[122] Wenger M, Mariani L, Kalbarczyk A, et al. Long-term outcome of

104 patients after lumbar sequestrectomy according to Williams.

Neurosurgery 2001;49:329–34; discussion 334–5.

[123] Tosteson AN, Skinner JS, Tosteson TD, et al. The cost effectiveness

of surgical versus nonoperative treatment for lumbar disc herniation

over two years: evidence from the Spine Patient Outcomes Research

Trial (SPORT). Spine 2008;33:2108–15.

[124] Hansson E, Hansson T. The cost-utility of lumbar disc herniation

surgery. Eur Spine J 2007;16:329–37.

[125] Malter AD, Larson EB, Urban N, et al. Cost-effectiveness of lumbar

discectomy for the treatment of herniated intervertebral disc. Spine

1996;21:1048–55.

191D.S. Kreiner et al. / The Spine Journal 14 (2014) 180–191