Lumbar disk herniation is a fairly common condition, with a reported prevalence of 1% to 3%.1 Following surgical treatment of lumbar disk herniation, recurrent lumbar disk herniation (RLDH) is estimated to occur in 5% to 11% of patients, with reoperation reported for up to 24% of these patients.2–6 Reoperation for RLDH is often performed when pain relief cannot be achieved following conservative measures, although revision surgery is not without additional challenges. The presence of scar tissue during reoperation increases the risk of neurological injury and dural tear.7 Further, there is also a potential for segmental instability with additional removal of disk material, leading some surgeons to believe fusion is necessary during revision surgery for RLDH.8,9
Currently, consensus is lacking in the literature and controversy exists regarding the optimal surgical treatment of RLDH. Geography, practice type, fellowship training, and annual case volume are factors that have been reported to influence surgeons' preference for surgical treatment of RLDH.10 Given these findings, a systematic review and meta-analysis of the literature was performed to help patients and surgeons make an informed decision on the optimal surgical treatment of RLDH. Specifically, the goal of this study was to compare the surgical treatment options for RLDH in relation to complications, re-recurrence of disk herniation, reoperation, and functional outcomes.
Materials and Methods
Search Strategy
A systematic search of Medline, Embase, Cochrane Reviews, Scopus, and Web of Science was performed to identify studies that reported on the clinical and/or functional outcomes of surgical treatment of RLDH. The search terms used included “disc herniation,” “lumbar disc herniation,” “lumbar disc re-herniation,” “recurrent lumbar disc herniation,” “discectomy,” “microdiscectomy,” and “fusion.” The search strategy was developed to include all study designs. English-language full-text manuscripts or abstracts were reviewed. Following review of all relevant reports, the references of articles selected for review were further assessed to identify studies that were not captured in the initial database search.
Selection of Studies
Studies that reported on clinical and/or functional outcomes following surgical treatment of RLDH at the same level were included. Studies on nonoperative management of RLDH were excluded. Case reports and non–English-language studies were also excluded.
Outcome Measures
Surgical treatment of RLDH was classified as decompression surgery (DS) or fusion surgery (FS). Decompression surgery was further subdivided into open diskectomy (OD) or endoscopic diskectomy (ED), whereas FS was further subdivided into posterolateral fusion (PLF) or posterior interbody fusion (PIF). Primary outcome measures included clinical outcomes (eg, dural tear, wound infection, neurological complication, re-recurrence of disk herniation, and reoperation) as well as functional outcome (eg, the Japanese Orthopaedic Association [JOA] score, the Oswestry Disability Index [ODI] score, and the visual analog scale [VAS] scores for back and leg pain).
Data Extraction
Two of the authors (R.M.A., A.D.) reviewed and extracted data from studies that fulfilled all inclusion and exclusion criteria. The following variables were extracted from each study: year of study, type of study, level of evidence, demographic data, follow-up time, type of surgery, complications (eg, dural tear, wound infection, and neurological complication), re-recurrence of disk herniation, reoperation, and functional outcome measures (eg, JOA score, ODI score, and VAS scores for back and leg pain).
Assessment of Level of Evidence and Methodological Quality of the Studies
Two of the authors (R.M.A., S.P.) conducted a quality assessment for each of the studies selected for final analysis. Level of evidence ratings were assigned to the studies using the criteria set forth by Wright et al.11 Quality assessment of all of the selected reports was performed by using the 12-point Methodological Index for Non-randomized Studies criteria (Table 1). These criteria have been previously reported to have high test–retest, external and internal validity, and interobserver reliability.42 The risk of bias of comparative studies was assessed using the Cochrane Back Review Group tool (Tables 2–3).43 If a study met at least 6 of the 12 criteria, the study was labeled as low risk of bias. If 5 or fewer of the 12 criteria were met, the study was labeled as high risk of bias. For non-comparative studies, risk of bias was assessed using a modified 5-point assessment score as previously described.44 Inconsistencies in methodologic quality assessment were reconciled through discussion with a third author (A.D.).
Data Analysis
The data were analyzed using the random effects model with inverse variance weighting. Meta-analyses and forest plots were constructed using the statistical software Review Manager (RevMan; version 5.3; Cochrane, London, England). Summary effects and 95% confidence intervals (CIs) were the primary summary measures. Individual studies were compared via 95% CIs and forest plots. Meta-analysis was completed to determine the incidence of dural tear, wound infection, neurological complication, re-recurrence of disk herniation, and reoperation following each surgical treatment modality. Effect incidence was determined by dividing the number of patients noted with a given variable of interest by the total patient cohort size in each study. Furthermore, meta-analysis was used to compare changes between pre- and postoperative JOA, ODI and VAS back and leg scores. Heterogeneity was evaluated between individual studies with a Q statistic and I2 value for each meta-analysis. As described by DeLong et al,45I2 heterogeneity less than 25% generally indicates consistent results and homogeneous studies, whereas 25% to 75% indicates moderate heterogeneity and greater than 75% indicates severe heterogeneity.
Results
Studies
Overall, the initial search yielded 1734 citations, of which 1658 were excluded from screening of the abstracts. Seventy-six studies were screened, with 42 being excluded because they described nonoperative management of RLDH or did not report on clinical and functional outcomes of RLDH. Thirty-four studies fulfilled all inclusion and exclusion criteria and were included in this systematic review (Figure 1).
Five of the studies were comparative studies on different surgical techniques for the treatment of RLDH. One study compared OD, PIF, and PLF, while 3 studies compared OD with ED. Another study compared OD with PLF. The remaining 29 studies included in this systematic review were noncomparative studies.
Quality Assessment of Included Studies
All studies were published as level II, III, or IV evidence (Table 1). The Methodological Index for Non-randomized Studies scores of the studies ranged from 8 to 19 (average, 12.6; SD, 3.4) (Table 1). All studies included in this review were of good methodologic quality with low risk of bias (Tables 2–3).
Demographics
The number of patients ranged from 6 to 262 patients per study. The reported mean patient age ranged from 39 to 61.2 years. The mean follow-up time ranged from 4.5 to 146.8 months (Table 4).
Clinical Outcomes of Decompression Versus Fusion Surgery
The incidence of dural tear was 6.1% (95% CI, −35.6% to 47.8%) for DS compared with 5.3% (95% CI, −35.3% to 4.6%) for FS. The incidence of infection was 0.6% (95% CI, −16.4% to 17.6%) for DS compared with 4.7% (95% CI, −31.1% to 40.6%) for FS (Table 5). The incidence of neurological complications was 1.9% (95% CI, −19.2% to 23.0%) following DS compared with 5.3% (95% CI, −35.4% to 45.9%) following FS. The incidence of re-recurrent disk herniation was 5.2% (95% CI, −37.0% to 47.5%) following DS compared with 0.0% (95% CI, −16.2% to 16.2%) following FS (Table 5). The incidence of reoperation was 5.4% (95% CI, −34.5% to 44.8%) following DS compared with 12.1% (95% CI, −54.3% to 78.5%) following FS (Table 5).
Endoscopic Diskectomy
The incidence of dural tear following ED was 3.2% (95% CI, −27.3% to 34.0%), whereas the incidence of infection and neurological complication were 0.0% (95% CI, −13.7% to 13.4%) and 0.0% (95% CI, −12.3% to 12.3%), respectively (Table 5). Following ED, the incidence of disk herniation re-recurrence was 5.3% (95% CI, −35.0% to 44.7%) and the incidence of reoperation was 2.5% (95% CI, −29.4% to 34.4%) (Table 5).
Open Diskectomy
Following OD, the incidence of dural tear was 10.8% (95% CI, −50.2% to 71.8%) and the incidence of infection was 1.7% (95% CI, −21.2% to 24.6%) (Table 5). The incidence of neurological complication was 3.4% (95% CI, −24.7% to 31.6%), and the incidence of disk herniation re-recurrence was 5.2% (95% CI, −36.1% to 46.5%) (Table 5). Following OD, the incidence of reoperation was 7.8% (95% CI, −39.6% to 55.1%) (Table 5).
Posterolateral Fusion
Following PLF, the incidence of dural tear was 8.9% (95% CI, −49.1% to 66.9%) and the incidence of infection was 2.8% (95% CI, −28.3% to 33.9%) (Table 5). The number of studies was insufficient to calculate the frequency of neurological complication, disk herniation re-recurrence, and reoperation following PLF.
Posterior Interbody Fusion
Following PIF, the incidence of dural tear was 4.3% (95% CI, −31.3% to 39.8%) and the incidence of infection was 5.5% (95% CI, −32.3% to 43.3%) (Table 5). The incidence of neurological complication was 6.0% (95% CI, −38.2% to 50.2%), and the incidence of disk herniation re-recurrence was 0.0% (95% CI, −16.3% to 16.3%) (Table 5). Following PIF, the incidence of reoperation was 12.4% (95% CI, −54.3% to 79.2%) (Table 5).
Functional Outcomes of Decompression Versus Fusion Surgery
Decompression surgery and FS both resulted in improvements in JOA, ODI, and VAS back and leg scores postoperatively: DS=+12.95, (JOA: P<.00001), −38.46 (ODI: P<.00010), −3.88 (VAS back: P=.00100), and −5.66 (VAS leg: P<.00001); and FS=+14.26 (JOA: P<.00001), −28.33 (ODI: P=.05000), −5.32 (VAS back: P<.00001), and −6.34 (VAS leg: P<.00001) (Table 6; Figures 2–9).
Endoscopic Diskectomy
Following ED, mean decrease in ODI, VAS back, and VAS leg scores compared with preoperative values was 28.67 (95% CI, 14.69 to 42.66; P<.00001), 3.05 (95% CI, 1.70 to 4.40; P<.00001), and 5.70 (95% CI, 5.38 to 6.01; P<.00001), respectively (Table 6). The number of studies was insufficient to calculate the mean improvement of JOA scores.
Open Diskectomy
Following OD, mean JOA score improved by 12.95 (95% CI, 10.17 to 15.75; P<.00001) compared with preoperative values, whereas mean ODI and VAS back scores decreased by 53.12 (95% CI, 38.39 to 67.86; P=.00600) and 4.76 (95% CI, 0.06 to 9.47; P=.05000), respectively (Table 6). The number of studies was insufficient to calculate the mean improvement of VAS leg scores.
Posterolateral Fusion
Following PLF, the mean improvement in JOA scores compared with preoperative values was 14.07 (95% CI, 8.49 to 19.66; P<.00001) (Table 6). The number of studies was insufficient to calculate the mean improvement of ODI, VAS back, and VAS leg scores.
Posterior Interbody Fusion
Following PIF, the mean improvement in JOA score was 15.26 (95% CI, 13.87 to 16.65; P<.00001) compared with preoperative values. Mean ODI, VAS back, and VAS leg scores decreased 28.33 (95% CI, 0.46 to 56.21; P=.05000), 5.32 (95% CI, 3.94 to 6.69; P<.00001), and 6.34 (95% CI, 4.62 to 8.07; P<.00001), respectively (Table 6).
Discussion
Recurrent lumbar disk herniation is estimated to occur in 5% to 11% of patients, with reoperation reported for up to 24% of these patients.2–6 Currently, there is a lack of consensus in the literature regarding the optimal surgical treatment of RLDH and whether DS alone is sufficient or if there is added benefit or harm to performing DS and FS. Given the lack of prospective and comparative studies in the current literature, a systematic review and meta-analysis was performed to better address this issue to guide surgical decision-making. In this study, the authors found that there is a tremendous amount of variability regarding complications, re-recurrence of lumbar disk herniation, and reoperations in patients undergoing DS or FS for RLDH. However, DS and FS both lead to improvements in functional outcomes as measured by JOA, ODI, and VAS back and leg scores postoperatively.
Reoperation for RLDH is theoretically associated with increased complications and injury to the neural elements because of the formation of scar tissue and potential loss of normal anatomic landmarks. In this study, the incidence of dural tears was noted to be 6.1% for DS compared with 5.3% for FS. These numbers are in line with the literature, which reports an estimated incidence of 4% to 10% in revision cases.7,21,30,34,35 The incidence of neurological complications was 1.9% following DS compared with 5.3% following FS. Nerve root retraction during placement of an interbody device and pedicle screw malposition have been implicated as factors that lead to nerve injury following lumbar fusion surgery.46–48
The incidence of infection following spine surgery is estimated to range from almost less than 1% to 6%.49–54 For lumbar disk herniation surgery, infection rates of approximately 0.1% to 4% have been reported, with variation based on type of procedure and patient factors.51,52,54 Procedures involving placement of instrumentation have been theorized to carry a higher risk of infection because the surface layer of these implants could serve as a nidus for bacterial growth. Additionally, prolonged operative time and perioperative surgical complications have also been implicated as risk factors for infections.55 In this study, the incidence of infection was 4.7% for FS compared with 0.6% for DS.
Re-recurrent lumbar disk herniation poses a challenging clinical scenario, and there is currently no clinical guideline or consensus on its optimal surgical management. This study found the incidence of re-recurrent disk herniation to be 5.2% for DS compared with 0.0% for FS. On the other hand, the incidence of reoperation was 5.4% following DS compared with 12.1% following FS. In fusion procedures, motion in a diseased disk segment is eliminated, resulting in less mechanical stress at the disk space. In addition, a near-total diskectomy is often performed, which results in less opportunity for disk re-herniation. As such, procedures involving DS are theoretically at a higher risk of re-herniation because motion is preserved. Despite the decreased chance for re-herniation associated with FS, these procedures are not without complications. In this study, the primary reasons for reoperation following FS included implant complications, pseudarthrosis, and adjacent segment disease.56–58 Conversely, the primary reason for reoperation following DS was same-level re-herniation.59–61 As such, the risk of disk re-herniation associated with motion-preserving procedures must be weighed against the risk of implant-related complications, pseudarthrosis, and adjacent segment disease associated with fusion procedures.
Finally, both DS and FS techniques resulted in improvements in all functional outcome scores evaluated in this study, which included JOA, ODI, and VAS back and leg pain scores. This implies that surgical intervention for recurrent lumbar disk herniation leads to improved outcomes regardless of which surgical option is performed. The complications profile, risk of herniation, and risk of reoperation of a given procedure need to be considered when deciding which revision surgical intervention will be most effective for an individual patient.
Limitations
There were limitations inherent to this meta-analysis. It was subject to the cumulative weaknesses of the included studies. This review included predominantly retrospective studies, most of which were non-comparative studies. Unfortunately, there is no sufficient body of evidence in the literature involving prospective studies and randomized controlled trials. These retrospective studies were included to amass sufficient data for comparison, as only 7 comparative studies of surgical treatment of RLDH were available in this review.
Additionally, there was a significant amount of heterogeneity between the included studies regarding surgeon technique. Standardization of patient age and reporting of patient activity level across all studies were lacking—factors that may influence the risk of RLDH. Also, there were inherent differences in the patient selection process preoperatively that were the result of surgeon preference for a specific surgical technique for different patient populations. This contributed to bias in the study design. Finally, the length of follow-up among the included studies was an additional source of variation, with reported complications and disk re-herniation rates subject to duration of patient follow-up in each study.
Despite these limitations, this study provides important aggregate data that can help drive decision-making regarding the type of surgical technique to address RLDH.
Conclusion
Decompression surgery and FS are viable surgical options to address RLDH. The complication risk profile of each procedure must be balanced with the risk of disk herniation recurrence and reoperation, as both procedures lead to improvements in JOA, ODI, and VAS back and leg scores postoperatively. Randomized trials assessing the clinical and functional outcomes of DS and FS, and possibly disk replacement, are needed to determine the optimal surgical technique to address RLDH.
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- Shousha M, Cirovic D, Boehm H. Infection rate after minimally invasive noninstrumented spinal surgery based on 4350 procedures. Spine (Phila Pa 1976). 2015; 40(3):201–205. doi:10.1097/BRS.0000000000000690 [CrossRef]
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- Martin BI, Mirza SK, Comstock BA, Gray DT, Kreuter W, Deyo RA. Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Spine (Phila Pa 1976). 2007; 32(3):382–387. doi:10.1097/01.brs.0000254104.55716.46 [CrossRef]
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Level of Evidence Ratings and Quality Assessment Using the 12-Point Methodological Index for Non-randomized Studies Criteriaa
| Study | Level of Evidence | Clearly Stated Aim | Inclusion of Consecutive Patients | Prospective Collection of Data | End-points Appropriate for Study Aim | Unbiased Assessment of Study Endpoint | Follow-up Appropriate for Study Aim | Loss to Follow-up <5% | Prospective Calculation of Study Size | Adequate Control Group | Contemporary Groups | Baseline Equivalence of Groups | Adequate Statistical Analysis | MINORS Score |
|---|
| El Shazly et al12 | II | 2 | 2 | 2 | 2 | 0 | 2 | 2 | 0 | 2 | 2 | 2 | 0 | 18 |
| Ruetten et al13 | II | 2 | 2 | 2 | 2 | 1 | 2 | 2 | 0 | 2 | 2 | 2 | 0 | 19 |
| Sonmez et al14 | II | 2 | 2 | 2 | 2 | 0 | 2 | 2 | 0 | 2 | 2 | 2 | 0 | 18 |
| Chen et al15 | III | 2 | 2 | 0 | 2 | 0 | 2 | 2 | 0 | 2 | 2 | 2 | 0 | 16 |
| Lee et al16 | III | 2 | 2 | 2 | 2 | 1 | 2 | 2 | 0 | 2 | 2 | 2 | 0 | 19 |
| Fu et al17 | III | 2 | 2 | 1 | 2 | 0 | 2 | 2 | 0 | 2 | 2 | 2 | 0 | 17 |
| Hou et al18 | IV | 2 | 2 | 1 | 2 | 2 | 2 | 2 | N/A | N/A | N/A | N/A | N/A | 13 |
| Ibrahim et al19 | IV | 2 | 0 | 2 | 2 | 0 | 2 | 2 | N/A | N/A | N/A | N/A | N/A | 10 |
| Hoogland et al20 | IV | 2 | 2 | 2 | 2 | 1 | 2 | 0 | N/A | N/A | N/A | N/A | N/A | 11 |
| Isaacs et al21 | IV | 2 | 2 | 0 | 2 | 0 | 2 | 2 | N/A | N/A | N/A | N/A | N/A | 10 |
| Le et al7 | IV | 2 | 2 | 0 | 2 | 0 | 2 | 2 | N/A | N/A | N/A | N/A | N/A | 10 |
| Li et al22 | IV | 2 | 2 | 2 | 2 | 2 | 2 | 2 | N/A | N/A | N/A | N/A | N/A | 14 |
| Kim et al23 | IV | 2 | 2 | 0 | 2 | 2 | 2 | 2 | N/A | N/A | N/A | N/A | N/A | 12 |
| Lequin et al24 | IV | 2 | 2 | 0 | 2 | 0 | 2 | 2 | N/A | N/A | N/A | N/A | N/A | 10 |
| Niesche et al25 | IV | 2 | 2 | 0 | 2 | 0 | 2 | 2 | N/A | N/A | N/A | N/A | N/A | 10 |
| Omidi-Kashani et al26 | IV | 2 | 2 | 1 | 2 | 0 | 2 | 2 | N/A | N/A | N/A | N/A | N/A | 11 |
| Nomura et al27 | III | 2 | 2 | 1 | 2 | 0 | 2 | 2 | 0 | 2 | 2 | 2 | 0 | 17 |
| Ahsan et al2 | III | 2 | 2 | 0 | 2 | 0 | 2 | 2 | 0 | 2 | 2 | 2 | 0 | 16 |
| Eloqayli and Alomari28 | IV | 2 | 2 | 2 | 2 | 0 | 0 | 2 | N/A | N/A | N/A | N/A | N/A | 10 |
| Kim et al29 (2) | IV | 2 | 2 | 0 | 2 | 0 | 2 | 2 | N/A | N/A | N/A | N/A | N/A | 10 |
| Shin et al30 | IV | 2 | 0 | 0 | 2 | 0 | 2 | 2 | N/A | N/A | N/A | N/A | N/A | 8 |
| Smith et al31 | IV | 2 | 2 | 0 | 2 | 0 | 2 | 2 | N/A | N/A | N/A | N/A | N/A | 10 |
| Chen et al32(2) | IV | 2 | 2 | 1 | 2 | 2 | 2 | 2 | N/A | N/A | N/A | N/A | N/A | 13 |
| Kim et al33 (3) | IV | 2 | 2 | 0 | 2 | 0 | 2 | 2 | N/A | N/A | N/A | N/A | N/A | 10 |
| Guo et al34 | IV | 2 | 2 | 0 | 2 | 0 | 2 | 2 | N/A | N/A | N/A | N/A | N/A | 10 |
| Palma et al35 | IV | 2 | 2 | 0 | 2 | 0 | 2 | 2 | N/A | N/A | N/A | N/A | N/A | 10 |
| Papadopoulos et al36 | III | 2 | 2 | 0 | 2 | 0 | 2 | 2 | 0 | 2 | 2 | 2 | 0 | 16 |
| Dai et al37 | IV | 2 | 2 | 0 | 2 | 0 | 2 | 2 | N/A | N/A | N/A | N/A | N/A | 10 |
| Niu et al38 | IV | 2 | 2 | 0 | 2 | 0 | 2 | 2 | N/A | N/A | N/A | N/A | N/A | 10 |
| Ahn et al5 | IV | 2 | 2 | 1 | 2 | 2 | 2 | 2 | N/A | N/A | N/A | N/A | N/A | 13 |
| Suk et al39 | IV | 2 | 2 | 0 | 2 | 0 | 2 | 2 | N/A | N/A | N/A | N/A | N/A | 10 |
| Cinotti et al8 | III | 2 | 2 | 0 | 2 | 2 | 2 | 2 | 0 | 2 | 2 | 2 | 0 | 18 |
| Herron40 | IV | 2 | 2 | 0 | 2 | 0 | 2 | 2 | N/A | N/A | N/A | N/A | N/A | 10 |
| Silvers et al41 | IV | 2 | 2 | 0 | 2 | 0 | 2 | 2 | N/A | N/A | N/A | N/A | N/A | 10 |
Risk of Bias and Quality Assessment of the Comparative Studies
| Study | Adequate Randomization | Allocation Concealment | Blinding of Patients | Blinding of Care Providers | Blinding of Outcome Assessors | Baseline Comparability | Dropout Rate Described | Free of Selective Outcome Reporting | Co-interventions Were Similar | Acceptable Compliance Between Groups | Intention-to-Treat Analysis | Similar Outcome Assessment | Total Score | Risk of Biasa |
|---|
| El Shazly et al12 | 1 | 0 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 8 | Low |
| Ruetten et al13 | 1 | 0 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 8 | Low |
| Sonmez et al14 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 7 | Low |
| Chen et al15 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 7 | Low |
| Lee et al16 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 7 | Low |
| Fu et al17 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 7 | Low |
| Nomura et al27 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 7 | Low |
| Ahsan et al2 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 7 | Low |
| Papadopoulos et al36 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 7 | Low |
| Cinotti et al8 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 7 | Low |
Risk of Bias and Quality Assessment of the Noncomparative Studies
| Study | Patient Selection/Inclusion Described | Drop-out Rate Described | Independent Assessor | Cointerventions Described | Timing of Outcome Assessment Similar | Total Score | Risk of Biasa |
|---|
| Hou et al18 | 1 | 1 | 0 | 1 | 1 | 4 | Low |
| Ibrahim et al19 | 1 | 1 | 0 | 0 | 1 | 3 | Low |
| Hoogland et al20 | 1 | 1 | 0 | 0 | 1 | 3 | Low |
| Isaacs et al21 | 1 | 1 | 0 | 0 | 1 | 3 | Low |
| Le et al7 | 1 | 1 | 0 | 0 | 1 | 3 | Low |
| Li et al22 | 1 | 1 | 1 | 0 | 1 | 4 | Low |
| Kim et al23 | 1 | 1 | 0 | 0 | 1 | 3 | Low |
| Lequin et al24 | 1 | 1 | 0 | 0 | 1 | 3 | Low |
| Niesche et al25 | 1 | 1 | 0 | 0 | 1 | 3 | Low |
| Omidi-Kashani et al26 | 1 | 1 | 0 | 1 | 1 | 4 | Low |
| Eloqayli and Al-omari28 | 1 | 1 | 0 | 0 | 1 | 3 | Low |
| Kim et al29 (2) | 1 | 1 | 0 | 0 | 1 | 3 | Low |
| Shin et al30 | 1 | 1 | 0 | 0 | 1 | 3 | Low |
| Smith et al31 | 1 | 1 | 0 | 0 | 1 | 3 | Low |
| Chen et al32 (2) | 1 | 1 | 0 | 0 | 1 | 3 | Low |
| Kim et al33 (3) | 1 | 1 | 0 | 0 | 1 | 3 | Low |
| Guo et al34 | 1 | 1 | 0 | 0 | 1 | 3 | Low |
| Palma et al35 | 1 | 1 | 0 | 0 | 1 | 3 | Low |
| Dai et al37 | 1 | 1 | 0 | 0 | 1 | 3 | Low |
| Niu et al38 | 1 | 1 | 0 | 0 | 1 | 3 | Low |
| Ahn et al5 | 1 | 1 | 1 | 0 | 1 | 3 | Low |
| Suk et al39 | 1 | 1 | 0 | 0 | 1 | 3 | Low |
| Herron40 | 1 | 1 | 0 | 0 | 1 | 3 | Low |
| Silvers et al41 | 1 | 1 | 0 | 0 | 1 | 3 | Low |
Study Characteristics
| Study | Publication Year | Study Design | Treatment Method | No. of Patients | Mean Age, y | Mean Follow-up, mo |
|---|
| El Shazly et al12 | 2013 | Prospective | OD | 15 | 41 | 38.6 |
| PIF | 15 | 40.5 | 36.3 |
| PLF | 15 | 42.7 | 36.1 |
| Ruetten et al13 | 2009 | Prospective | OD | N/A | 39 | 24 |
| ED | N/A | 39 | 24 |
| Sonmez et al14 | 2012 | Prospective | PIF | 20 | 46.5 | N/A |
| Chen et al15 | 2015 | Retrospective | ED | 18 | 57.4 | N/A |
| OD | 25 | 54.9 | N/A |
| Lee et al16 | 2009 | Retrospective | ED | 25 | 42 | 34 |
| OD | 29 | 47.7 | 34.3 |
| Fu et al17 | 2005 | Retrospective | OD | 23 | 41.1 | 85.6 |
| PLF | 18 | 42.2 | 92.6 |
| Hou et al18 | 2015 | Prospective | ED | 25 | 50 | 36 |
| Ibrahim et al19 | 2015 | Prospective | OD | 34 | 45.1 | 27.1 |
| Hoogland et al20 | 2008 | Prospective | ED | 262 | 46.4 | 24 |
| Isaacs et al21 | 2003 | Prospective | ED | 10 | N/A | 13.1 |
| Le et al7 | 2003 | Prospective | ED | 10 | N/A | 18.5 |
| Li et al22 | 2015 | Retrospective | PIF | 73 | 46.2 | 49.2 |
| Kim et al23 | 2014 | Retrospective | ED | 26 | 53.1 | 19.3 |
| Lequin et al24 | 2014 | Retrospective | PIF | 26 | 45.7 | 15.3 |
| Niesche et al25 | 2014 | Retrospective | PIF | 33 | 57 | 50.2 |
| Omidi-Kashani et al26 | 2014 | Retrospective | PIF | 51 | 46.4 | 31.4 |
| Nomura et al27 | 2013 | Retrospective | ED | 27 | N/A | N/A |
| Ahsan et al2 | 2012 | Retrospective | OD | 18 | 39 | N/A |
| Eloqayli and Al-omari28 | 2012 | Retrospective | ED | 6 | 45 | 4.5 |
| Kim et al29 (2) | 2012 | Retrospective | ED | 10 | 61.2 | 14.4 |
| Shin et al30 | 2011 | Retrospective | ED | 41 | 42.9 | 16 |
| Smith et al31 | 2010 | Retrospective | ED | 16 | N/A | 14.7 |
| Chen et al32 (2) | 2009 | Retrospective | PIF | 43 | 54.2 | 45 |
| Kim et al33 (3) | 2009 | Retrospective | OD | 14 | 44.6 | N/A |
| Guo et al34 | 2008 | Retrospective | OD | 51 | 42.2 | 146.8 |
| Palma et al35 | 2008 | Retrospective | OD | 95 | N/A | N/A |
| Papadopoulos et al36 | 2006 | Retrospective | OD | 27 | 39.2 | N/A |
| Dai et al37 | 2005 | Retrospective | OD | 39 | N/A | 92 |
| Niu et al38 | 2005 | Retrospective | PIF | 14 | 44 | 25 |
| Ahn et al5 | 2004 | Retrospective | ED | 43 | 45.5 | 31 |
| Suk et al39 | 2001 | Retrospective | OD | 28 | 42.1 | N/A |
| Cinotti et al8 | 1999 | Retrospective | OD | 16 | 44 | 24 |
| Herron40 | 1994 | Retrospective | OD | 50 | N/A | 54 |
| Silvers et al41 | 1994 | Retrospective | OD | 82 | N/A | 54 |
Effect Incidence of Clinical Outcomes Based on Type of Surgery
| Type of Surgery | Clinical Variables of Interest | No. of Studies | Effect Incidence | 95% Confidence Interval | Q | I2 |
|---|
| Fusion surgery | Dural tear | 9 | 5.3% | −35.3% to 4.6% | 13.497 | 40.73 |
| Infection | 7 | 4.7% | −31.1% to 40.6% | 18.987 | 68.4 |
| Neurological complication | 8 | 5.3% | −35.4% to 45.9% | 17.577 | 60.175 |
| Re-recurrence | 3 | 0.0% | −16.2% to 16.2% | 0 | 0 |
| Reoperation | 4 | 12.1% | −54.3% to 78.5% | 4.0809 | 26.4877 |
| Decompression surgery | Dural tear | 22 | 6.1% | −35.6% to 47.8% | 106.7688 | 80.331344 |
| Infection | 20 | 0.6% | −16.4% to 17.6% | 187.62444 | 89.8733877 |
| Neurological complication | 9 | 1.9% | −19.2% to 23.0% | 51.9513 | 84.6009 |
| Re-recurrence | 16 | 5.2% | −37.0% to 47.5% | 30.21012 | 50.347767 |
| Reoperation | 12 | 5.4% | −34.5% to 44.8% | 65.2477 | 83.14117 |
| Endoscopic diskectomy | Dural tear | 14 | 3.2% | −27.3% to 34.0% | 60.8951 | 78.6518 |
| Infection | 13 | 0.0% | −13.7% to 13.4% | 0 | 0 |
| Neurological complication | 4 | 0.0% | −12.3% to 12.3% | 0 | 0 |
| Re-recurrence | 12 | 5.3% | −35.0% to 44.7% | 28.705 | 61.6796 |
| Reoperation | 6 | 2.5% | −29.4% to 34.4% | 5.5705 | 10.2425 |
| Open diskectomy | Dural tear | 8 | 10.8% | −50.2% to 71.8% | 8.6646 | 19.2122 |
| Infection | 7 | 1.7% | −21.2% to 24.6% | 41.0630109 | 85.3883 |
| Neurological complication | 5 | 3.4% | −24.7% to 31.6% | 23.7883 | 83.185013 |
| Re-recurrence | 5 | 5.2% | −36.1% to 46.5% | 3.30098 | 0 |
| Reoperation | 6 | 7.8% | −39.6% to 55.1% | 2.6427 | 0 |
| Posterolateral fusion | Dural tear | 2 | 8.9% | −49.1% to 66.9% | 1 | 0 |
| Infection | 2 | 2.8% | −28.3% to 33.9% | 1 | 0 |
| Neurological complication | N/A | N/A | N/A | N/A | N/A |
| Re-recurrence | N/A | N/A | N/A | N/A | N/A |
| Reoperation | N/A | N/A | N/A | N/A | N/A |
| Posterior interbody fusion | Dural tear | 7 | 4.3% | −31.3% to 39.8% | 13.12411 | 54.28263 |
| Infection | 5 | 5.5% | −32.3% to 43.3% | 13.16926 | 69.62624 |
| Neurological complication | 7 | 6.0% | −38.2% to 50.2% | 10.0141655 | 40.084873 |
| Re-recurrence | 2 | 0.0% | −16.3% to 16.3% | 0 | 0 |
| Reoperation | 3 | 12.4% | −54.3% to 79.2% | 2.0177022 | 0.87734 |
Meta-analysis of Changes Between Pre- and Postoperative Functional Outcome Scores Based on Type of Surgery
| Type of Surgery | Functional Outcome of Interest | No. of Studies | Mean Difference Between Preoperative and Postoperative Scores | 95% Confidence Interval | P | Q | I2 |
|---|
| Fusion surgery | JOA | 4 | 14.26 | 11.54 to 16.99 | <.00001 | 16.50 | 82% |
| ODI | 3 | −28.33 | −56.21 to −0.46 | .05000 | 252.12 | 99% |
| VASB | 4 | −5.32 | −6.69 to −3.94 | <.00001 | 70.40 | 96% |
| VASL | 4 | −6.34 | −8.07 to −4.62 | <.00001 | 60.10 | 95% |
| Decompression surgery | JOA | 3 | 12.95 | 10.17 to 15.75 | <.00001 | 8.54 | 77% |
| ODI | 5 | −38.46 | −56.93 to −19.99 | <.00010 | 184.15 | 98% |
| VASB | 6 | −3.88 | −6.24 to −1.52 | .00100 | 134.19 | 96% |
| VASL | 7 | −5.66 | −5.97 to −5.36 | <.00001 | 5.80 | 0% |
| Endoscopic diskectomy | JOA | N/A | | | | | |
| ODI | 3 | −28.67 | −42.66 to −14.69 | <.00001 | 28.95 | 93% |
| VASB | 4 | −3.05 | −4.40 to −1.70 | <.00001 | 10.60 | 72% |
| VASL | 6 | −5.70 | −6.01 to −5.38 | <.00001 | 5.02 | 0% |
| Open diskectomy | JOA | 3 | 12.95 | 10.17 to 15.75 | <.00001 | 8.54 | 77% |
| ODI | 2 | −53.12 | −67.86 to −38.39 | .00600 | 7.53 | 87% |
| VASB | 2 | −4.76 | −9.47 to −0.06 | .05000 | 30.61 | 97% |
| VASL | N/A | N/A | N/A | N/A | N/A | N/A |
| Posterolateral fusion | JOA | 2 | 14.07 | 8.49 to 19.66 | <.00001 | 9.42 | 89% |
| ODI | N/A | N/A | N/A | N/A | N/A | N/A |
| VASB | N/A | N/A | N/A | N/A | N/A | N/A |
| VASL | N/A | N/A | N/A | N/A | N/A | N/A |
| Posterior interbody fusion | JOA | 2 | 15.26 | 13.87 to 16.65 | <.00001 | 6.34 | 84% |
| ODI | 3 | −28.33 | −56.21 to −0.46 | .05000 | 252.12 | 99% |
| VASB | 4 | −5.32 | −6.69 to −3.94 | <.00001 | 70.40 | 96% |
| VASL | 4 | −6.34 | −8.07 to −4.62 | <.00001 | 60.10 | 95% |