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Rushton A.1, Heneghan N.1, Heymans M.2, Staal J.B.3, Goodwin P.4
1University of Birmingham, School of Sport, Exercise and Rehabilitation Sciences, Birmingham, United Kingdom, 2VU University Medical Center, Department of Epidemiology and Biostatistics, Amsterdam, Netherlands, 3Scientific Institute for Quality of Healthcare (IQ Healthcare), Nijmegen, Netherlands, 4Manchester Metropolitan University, Health Professions Department (Physiotherapy), Manchester, United Kingdom
Background: Although lumbar discectomy success rates are reported as high (46-75% at 6-8 weeks, and 78-95% at 1-2 years post surgery), ongoing problems are an issue for a substantial number of patients. The evidence suggests that 30% to 70% of patients continue to experience pain and that 3% to 12% require further surgery. Knowledge about the natural clinical course post-surgery is needed to improve understanding of recovery to inform the timing and nature of physical therapy intervention.
Purpose: To provide the first evidence synthesis investigating the natural clinical course of disability and pain in patients aged >16 years post primary lumbar discectomy.
Methods: A systematic review and meta-analysis was conducted according to a pre-defined and published protocol; registered with PROSPERO (CRD42015020806). Prospective cohorts that included a well-defined inception cohort (point of surgery) of adult participants who had undergone primary lumbar discectomy / microdiscectomy were included. Outcomes included measurements reported for disability or pain (leg, back pain), with a baseline pre-surgery. Two reviewers independently searched information sources, assessed identified studies for inclusion, extracted data and assessed risk of bias for included studies. A third reviewer mediated any disagreement at each stage. The search employed sensitive topic-based strategies designed for each database from inception to 31 January 2016. There were no language or geographical restrictions. Risk of bias was assessed using a modified QUIPs tool (Quality in Prognostic Studies). Data synthesis was conducted on data where follow up was at least 80%. Means and 95% Confidence Intervals were plotted over time for leg pain, back pain and disability. Meta-analyses using a random effects model evaluated mean differences from baseline.
Results: Of the 3635 studies identified, 63 were included (n=18,563 participants). Few authors responded to requests for raw data. All results were reported in the context of study risk of bias (moderate / high for all studies). Few cohorts evaluated the initial 3-months period post surgery. Mean leg pain (VAS 0-10) was 7 pre-surgery. The mean difference from baseline at 3 months was -4.79 [95%CI -5.21,-4.37]; at 6 months was -5.34 [95%CI -6.03,-4.65]; and at 12 months was -5.15 [95%CI -5.68,-4.61]. Mean disability (ODI 0-100) was 53 pre-surgery. The mean difference from baseline at 3 months was -32.09 [95%CI -44.73,-19.45]; at 6 months was -33.68 [95%CI -48.32,-19.03]; and at 12 months was -35.78 [95%CI -44.32,-27.23]. Other outcomes and meta-analyses will be discussed.
Conclusion(s): These data demonstrate the initial improvement in outcomes following lumbar discectomy surgery, illustrating the initial success of surgery. However, the data highlight a subsequent plateau in improvement after 3 months, providing evidence of persistent pain and disability.
Implications: This review has provided the first rigorous summary of the course of pain and disability across all published prospective cohorts for adult patients following primary lumbar discectomy. The findings will inform our understanding of when to offer and how best to target physical therapy.
Funding acknowledgements: None
Topic: Musculoskeletal: spine
Ethics approval: Not applicable
All authors, affiliations and abstracts have been published as submitted.
