J Korean Soc Spine Surg.  2019 Dec;26(4):178-190. 10.4184/jkss.2019.26.4.178.

The Evidence for Nonoperative Treatment of Lumbar Spinal Diseases

Affiliations
  • 1Department of Orthopedic Surgery, Gangnam Severance Hospital, Seoul, Korea.
  • 2Department of Orthopedic Surgery, Seoul Sacred Heart Hospital, Seoul, Korea. adk0208@hanmail.net
  • 3Department of Orthopedic Surgery, Chonnam National University Hospital, National, Korea.
  • 4Department of Orthopedic Surgery, Kosin University Hospital, Busan, Korea.

Abstract

STUDY DESIGN: Review article.
OBJECTIVES
To assess the evidence for nonoperative treatment of various degenerative spinal degenerative diseases. SUMMARY OF LITERATURE REVIEW: No study has yet evaluated the evidence for preoperative nonoperative treatment of lumbar spinal diseases.
METHODS
The evidence regarding nonoperative treatment for each disease was reviewed through NASS guidelines, and the treatment effect compared to surgical treatment was reviewed through the SPORT series. The efficacy of nonoperative treatment according to disease severity and certain special conditions was investigated through corresponding individual articles.
RESULTS
No kind of nonoperative treatment could change the fundamental progression of degenerative spinal disease. The natural course of lumbar disc herniation is favorable regardless of treatment. More than 70% of routine cases improve within 6 weeks. However, it does not take a full 6 weeks to decide whether to perform surgery or not. The evidence for transforaminal epidural steroid injections for short-term pain control is grade A. There is grade B evidence for nonoperative treatment with the goal of mid- to long-term pain control. However, we cannot say that those outcomes are better than the natural course of the disease itself. In cases of radicular weakness, the degree of weakness is correlated with the final outcomes, but it is not evident whether the duration of weakness is correlated with surgical outcomes. Early surgery is usually necessary due to intolerable pain, rather than stable motor weakness. The social cost of herniated discs arises from the loss of patients' productivity, rather than from direct medical expenses. The natural course of spinal stenosis involves provoked pain and the need for palliative care. Unlike disc herniation, rapid deterioration and marked improvement do not occur. The symptoms of mild to moderate lumbar stenosis are unchanged in 70% of cases, improve in 15%, and worsen in 15%. No study has compared nonoperative treatment with the natural course of the disease. There is no evidence for nonoperative treatment of severe stenosis. Epidural spinal injections are effective for controlling short-term pain. Spontaneous recovery of radicular weakness does not occur, and urgent surgery is necessary in such cases. There is no evidence regarding the natural course and nonoperative treatment of degenerative spondylolisthesis. The working group consensus recommends that it should follow the pattern of nonoperative treatment of spinal stenosis when radicular stenosis symptoms are predominant. Overall, 40%-66% of cases of adult bilateral isthmic spondylolysis progress to symptomatic spondylolisthesis. No studies have investigated nonoperative treatment except physical exercise.
CONCLUSIONS
Although short-term symptom amelioration can be achieved by nonoperative treatment, the fundamental progression of the disease is not affected. For conditions excluded from most studies, such as prior spine surgery, cauda equina syndrome, progressive neurological deficit, and uncontrollable severe pain associated with instability, deformity, or vertebral fractures, there were not enough studies to reach informed conclusions. Our review found no evidence regarding nonoperative treatment for such conditions. Furthermore, the treatment methods for each disease are not clearly distinguished from each other, and the techniques used for disc herniation have been applied to other diseases without any evidence.

Keyword

Lumbar spine; Degenerative spinal disease; Nonoperative treatment

MeSH Terms

Adult
Congenital Abnormalities
Consensus
Constriction, Pathologic
Efficiency
Exercise
Humans
Injections, Spinal
Intervertebral Disc Displacement
Palliative Care
Polyradiculopathy
Spinal Diseases*
Spinal Stenosis
Spine
Spondylolisthesis
Spondylolysis
Sports

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