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1、Treatment of Lumbar Disc Herniation: An Evidence-Based Review 腰椎间盘突出症治疗的循证医学综述Wayne Moschetti, MD, Adam M. Pearson, MD, MS, and William A. Abdu, MD, MS Several randomized controlled trials (RCTs) and prospective observational cohort studies have compared surgical to conservative treatment for patien
2、ts with sciatica caused by lumbar disc herniation. Whereas no RCT has been able to compare surgery with nonoperative treatment without substantial crossover between treatment groups, multiple RCTs and observational studies have suggested that surgery resulted in faster improvement and a greater degr
3、ee of improvement compared with nonoperative treatment. However, many patients in these studies also experienced improvement with nonoperative care without adverse sequelae. This paper critically reviews the literature comparing surgery with nonoperative treatment for lumbar disc herniation. Semin S
4、pine Surg 21:223-229 2009 Elsevier Inc. All rights reserved. KEYWORDS Maine lumbar spine study, Spine Patient Outcomes Research Trial, sciatica, intervertebral disc herniation, low back pain, lumbar disc herniation 对于腰椎间盘突出导致的坐骨神经痛，有几项随机对照试验（RCTs）和前瞻性的观察队列研究对手术和保守治疗进行了比较。尽管目前还没有 RCT 能对手术和非手术治疗进行没有任何
5、组间交叉的比较，多项 RCT 和观察研究都认为与非手术治疗相比，手术可以获得更快、更大程度的改善。然而，在这些研究中很多患者通过非手术治疗也获得了改善，并且没有导致不良的后果。本文对文献进行审慎的综述，以对腰椎间盘突出症的手术和非手术治疗进行比较。关键词 缅因州腰椎研究；脊柱患者治疗结果研究试验；坐骨神经痛；椎间盘突出；腰痛；腰椎间盘突出ciatica is dened as pain radiating in an area of the leg that is served by a single nerve root in the lumbar or sacral spine and m
6、ay be associated with motor or sensory decits. A lumbar intervertebral disc herniation (IDH) is the most common cause of sciatica in working adults, with an estimated annual incidence of 5 per 1000 adults.1,2 Diskectomy is the most common lumbar spine surgery, and more than 250,000 elective lumbar s
7、pine surgeries occur each year in the USA.3 Many patients with sciatica will improve over time, yet surgery is frequently considered for patients with severe symptoms or symptoms that persist. Most spine surgeons agree that surgery should be offered only after a course of nonoperative treatment for
8、sciatica has failed. The most effective type and duration of conservative treatment has not been determined and varies substantially.4 In the USA, the rate of back surgery was found to be approximately 40% higher when compared with 11 other countries and was more than ve times the rate in England an
9、d Scotland.1 There is also signicant regional variation in the rate of diskectomy in the USA and internationally, suggesting that the indications for surgery are also variable.3,5 Given this substantial variation in the rate of surgery, it is clear that the appropriate timing of and indications for
10、surgery are inconsistent. The economic impact of back pain and sciatica is well known as demonstrated by a Dutch study concluding that low back pain was responsible for more time off work and disability than any other medical condition.6 In light of the uncertainty surrounding the outcomes of surgic
11、al and nonoperative treatment for lumbar IDH, this article aims to review the pertinent literature to assist spine care professionals in providing evidence-based recommendations to their patients. 坐骨神经痛是指小腿的放射性疼痛，该区域由起源于腰骶部的单一神经支配，并可伴有运动或感觉障碍。腰椎间盘突出（IDH）是导致成年劳动者坐骨神经痛最常见的原因，据估计成人每年的发生率约为 51,2。椎间盘切除术是
12、最常用的腰椎手术，在美国每年要实施超过 250000 例选择性的腰椎手术3。随着时间过去，很多患者的坐骨神经痛也可自行缓解，然而，对于症状持续或症状严重的患者，通常考虑手术治疗。大多数脊柱外科医生都认为，坐骨神经痛的患者只有经过系统的非手术治疗失败后，方可选择手术治疗。至于最有效的类型和合适的保守治疗期限，目前并没有统一的意见，且各种观点差异很大4。在美国，脊柱手术的比率高出其他 11 个国家约 40%，是英格兰和苏格兰的 5 倍余1。美国和国际上椎间盘切除术的比率也都存在着明显的地区差异，这提示各地手术适应证上的差异也很大3,5 。考虑到手术率上明显的差异，很显然，要确定适当的手术时机和手术
13、适应证是不太现实的。众所周知，背痛与坐骨神经痛可对经济产生明显的影响，荷兰学者的研究也证实了这一点，其结论认为腰痛导致的工作时间缺失以及劳动能力的丧失比任何其他疾病都要多6。考虑到腰椎间盘突出症手术和非手术治疗相关结果的不确定性，本文旨在综述相关文献，帮助脊柱外科医生向他们的患者提供循证医学建议。Webers Classic Randomized Control Trial In 1983, from a single referral center in Norway, Weber7 published the rst randomized control trial (RCT) compa
14、ring surgery and nonoperative treatment for patients with a herniated lumbar disc and radicular symptoms. Excluding patients with “intolerable” pain and those with “no indication” for operative intervention, this paper looked at 126 patients with “uncertain” indications for surgical treatment. These
15、 patients were randomized to surgical or nonoperative treatment. Follow-up examination was performed at 1, 4, and 10 years. Those undergoing surgery improved signicantly more on a descriptive outcome scale (good, fair, poor, bad) compared with those treated nonoperative at the 1-year follow-up exami
16、nation. Sixty-ve percent of surgical patients had a “good” outcome compared with 36% in the nonoperative group. At the 4-year follow up, the surgical patients still showed better results (70% “good” outcome vs 51% for nonoperative patients), but the difference was no longer statistically signicant. Only minor changes took place during the last 6 years of the study. Weber 经典随机对照试验1983 年，来自挪威一个转诊中心的 Weber7发表了比较手术和非手术治疗伴有根性症状的腰椎间盘突出的研究，这是针对该问题发表的第一个随机对照试验（
