Management of Symptomatic Lumbar Disk Herniation: An International Perspective

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The diversity among the current international practice patterns and the discrepancy between the eminence-based medicine and the evidence-based medicine in the treatment of lumbar disk herniation is presented. Minimally invasive techniques were expected to give the lowest postoperative low back pain, however, also to give the highest risk of recurrent disk herniation.Study Design.A questionnaire survey.Objective.To evaluate the current practice patterns of surgeons regarding both the surgical and nonsurgical management of lumbar disk herniation (LDH) worldwide and to compare this with the current literature.Summary of Background Data.Sciatica is a common diagnosis in the general population. Sciatica is most frequently caused by LDH. Multiple surgical techniques and treatment modalities are available to treat LDH, albeit some with small effect sizes or without compelling evidence.Methods.A survey including questions on the application of physical examination, expectations regarding different surgical and nonsurgical techniques, factors influencing the outcome of surgery were distributed among members of AOSpine International and the European Association of Neurosurgical Societies.Results.Eight hundred and seventeen surgeons from 89 countries completed the questionnaire. These surgeons perform a total of 62.477 discectomies yearly. Pain medication and steroid injections were expected to be the most effective nonsurgical treatments. The severity of pain and/ or disability and failure of conservative therapy were the most important indications for surgery. A period of 1 to 2 months of radiculopathy was regarded as a minimum for indicating surgery. Unilateral transflaval discectomy was the procedure of choice among the majority and was expected to be the most effective technique with the lowest complication risk. Surgeons performing more lumbar discectomies, with more clinical experience and those located in Asia, were more likely to offer minimally invasive surgical techniques.Conclusion.This study shows that current international practice patterns for LDH surgery are diverse. There seems to be a discrepancy between preferred surgical techniques and the attitudes of surgeons worldwide and the evidence. Further research should focus on developing international guidelines to reduce practice variety and offer patients the optimal treatment for LDH.Level of Evidence: N/A

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