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Indications for surgery versus conservative treatment in the management of lumbar disc herniations: A systematic review

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Title: Indications for surgery versus conservative treatment in the management of lumbar disc herniations: A systematic review
Authors: Santhosh G. Thavarajasingam, Ahmed Salih, Aksaan Arif, Madhur Varadpande, Pratheeshan Sabeshan, Hariharan Subbiah Ponniah, Sree Kanakala, Srikar R. Namireddy, Daniele S.C. Ramsay, Ahkash Thavarajasingam, Daniel Scurtu, Dragan Jankovic, Andreas Kramer, Florian Ringel
Source: Brain and Spine, Vol 5, Iss , Pp 105619- (2025)
Publisher Information: Elsevier, 2025.
Publication Year: 2025
Collection: LCC:Neurology. Diseases of the nervous system
Subject Terms: Lumbar disc herniation, Slipped disc, Surgical indications, Conservative management, Radiculopathy, Motor deficits, Neurology. Diseases of the nervous system, RC346-429
Description: Introduction: Lumbar disc herniation (LDH) is a leading cause of radiculopathy and low back pain, contributing significantly to global disability. Management strategies include conservative and surgical treatments, but clinical decision-making lacks standardization, particularly in surgical indications, timing, and criteria for transitioning from conservative management. Research question: What are the surgical indications, criteria for transitioning from conservative to surgical management in LDH, and what role do motor deficits play? Material and methods: Following PRISMA guidelines, a systematic search across major databases identified 20 studies. Risk of bias was assessed using the Newcastle Ottawa Scale and RoB 1 tools. A qualitative synthesis was conducted, and the Index of Qualitative Variation (IQV) quantified variability in indications. Results: Among the studies that reported specific indications, imaging-confirmed nerve root compression (reported in 18/20 studies) and severe/refractory pain (reported in 17/20 studies) were the most consistent indications, while thresholds for sensory deficits (reported in 8/20 studies) varied widely. Early surgery (48 h–6 weeks) was associated with superior recovery, particularly for mild/moderate motor deficits graded ≤ MRC 3/4, achieving >90 % recovery rates. Delayed surgery (>6 weeks) resulted in prolonged symptoms and poorer outcomes, especially in severe cases. Transition criteria included a patient-specific combination of failure of conservative therapy (n = 12) after a most frequently 4–6-week trial, neurological progression, and worsening imaging findings. Significant heterogeneity was observed in thresholds for motor and sensory deficits, with high IQV scores for definitions of conservative treatment failure (IQV = 0.96) and motor deficit (IQV = 0.96). Discussion and conclusion: Significant heterogeneity in surgical indications, timing, and decision-making highlights the urgent need for standardized, evidence-based guidelines to optimize clinical decisions and improve outcomes in LDH management.
Document Type: article
File Description: electronic resource
Language: English
ISSN: 2772-5294
Relation: http://www.sciencedirect.com/science/article/pii/S2772529425014389; https://doaj.org/toc/2772-5294
DOI: 10.1016/j.bas.2025.105619
Access URL: https://doaj.org/article/bfa182a1be5541e2993c33ae3d4c9cbf
Accession Number: edsdoj.bfa182a1be5541e2993c33ae3d4c9cbf
Database: Directory of Open Access Journals
Description
Abstract:Introduction: Lumbar disc herniation (LDH) is a leading cause of radiculopathy and low back pain, contributing significantly to global disability. Management strategies include conservative and surgical treatments, but clinical decision-making lacks standardization, particularly in surgical indications, timing, and criteria for transitioning from conservative management. Research question: What are the surgical indications, criteria for transitioning from conservative to surgical management in LDH, and what role do motor deficits play? Material and methods: Following PRISMA guidelines, a systematic search across major databases identified 20 studies. Risk of bias was assessed using the Newcastle Ottawa Scale and RoB 1 tools. A qualitative synthesis was conducted, and the Index of Qualitative Variation (IQV) quantified variability in indications. Results: Among the studies that reported specific indications, imaging-confirmed nerve root compression (reported in 18/20 studies) and severe/refractory pain (reported in 17/20 studies) were the most consistent indications, while thresholds for sensory deficits (reported in 8/20 studies) varied widely. Early surgery (48 h–6 weeks) was associated with superior recovery, particularly for mild/moderate motor deficits graded ≤ MRC 3/4, achieving >90 % recovery rates. Delayed surgery (>6 weeks) resulted in prolonged symptoms and poorer outcomes, especially in severe cases. Transition criteria included a patient-specific combination of failure of conservative therapy (n = 12) after a most frequently 4–6-week trial, neurological progression, and worsening imaging findings. Significant heterogeneity was observed in thresholds for motor and sensory deficits, with high IQV scores for definitions of conservative treatment failure (IQV = 0.96) and motor deficit (IQV = 0.96). Discussion and conclusion: Significant heterogeneity in surgical indications, timing, and decision-making highlights the urgent need for standardized, evidence-based guidelines to optimize clinical decisions and improve outcomes in LDH management.
ISSN:27725294
DOI:10.1016/j.bas.2025.105619