Clark R, Weber RP, Kahwati L Surgical Management of Lumbar Radiculopathy: a Systematic Review. J Gen Intern Med. 2019 Nov 11. pii: 10.1007/s11606-019-05476-8. doi: 10.1007/s11606-019-05476-8.
Abstract

BACKGROUND: Lumbar radiculopathy is characterized by radiating pain with or without motor weakness or sensory disturbances; the point prevalence ranges from 1.6 to 13.4%. The objective of this review was to determine the efficacy, safety, and cost of surgical versus nonsurgical management of symptomatic lumbar radiculopathy in adults.

METHODS: We searched PubMed from January 1, 2007, to April 10, 2019 with hand searches of systematic reviews for studies prior to 2007. One reviewer extracted data and a second checked for accuracy. Two reviewers completed independent risk of bias and strength of evidence ratings.

RESULTS: We included seven RCTs (N = 1158) and three cost-effectiveness analysis. Surgery reduced leg pain by 6 to 26 points more than nonsurgical interventions as measured on a 0- to 100-point visual analog scale of pain at up to 26 weeks follow-up; differences between groups did not persist at 1 year or later. The evidence was somewhat mixed for function and disability in follow-up through 26 weeks (standardized mean difference [SMD] - 0.16 (95% CI, - 0.30 to - 0.03); minimal differences were observed at 2 years (SMD - 0.06 (95% CI, - 0.20 to 0.07). There were similar improvements in quality of life, neurologic symptoms, and return to work. No surgical deaths occurred and surgical morbidity was infrequent. The incidence of reoperations ranged from 0 to 10%. The average cost per quality-adjusted life year gained from a healthcare payor perspective ranged from $51,156 to $83,322 for surgery compared to nonsurgical interventions.

DISCUSSION: Most findings are based on a body of RCT evidence graded as low to very low certainty. Compared with nonsurgical interventions, surgery probably reduces pain and improves function in the short- and medium-term, but this difference does not persist in the long-term. Although surgery appears to be safe, it may or may not be cost-effective depending on a decision maker's willingness to pay threshold.

Ratings by Clinicians (at least 3 per Specialty)
Specialty Score
Family Medicine (FM)/General Practice (GP)
General Internal Medicine-Primary Care(US)
Surgery - Orthopaedics
Internal Medicine
Special Interest - Pain -- Physician
Comments from MORE raters

Internal Medicine rater

As a hospitalist, I find that surgical management of back pain is an important consideration; this is a systematic review of studies that are between 10 and 20 years old and do not present new information. It just provides a new method to combine them; combining surgical studies with all of the differences in surgeon, technique, outcomes is fraught with tremendous potential confounders; this does not add much to what is already known - that surgery will make you feel good in the short run, especially if you are aware you had surgery, but not in the long run.

Surgery - Orthopaedics rater

The authors performed a systematic review in order to assess the efficacy, safety, and cost of surgical versus nonsurgical management of symptomatic lumbar radiculopathy in adults. Seven RCTs and three cost-effectiveness analysis were included. Surgery reduced leg pain more than nonsurgical interventions up to 26 weeks follow-up, but differences did not persist at 1 year. The evidence was somewhat mixed for function and disability. Similar improvements were found in quality of life, neurologic symptoms, and return to work. No surgical deaths occurred. The incidence of reoperations ranged from 0 to 10%. The average cost gained from a healthcare payor perspective ranged from $51,156 to $83,322 for surgery compared to nonsurgical interventions. Most findings are based on low to very low RCTs. Compared with nonsurgical interventions, surgery probably reduces pain and improves function in the short- and medium-term. Although surgery appears to be safe, it may not be cost-effective.