Comparison of 7 Surgical Interventions for Lumbar Disc Herniation: A Network Meta-analysis.

BACKGROUND The number of interventions on intervertebral discs rapidly increased and the treatment options for lumbar disc surgery quickly evolved. It is important that the safety and efficacy of all new innovative procedures be compared with currently accepted forms of treatment; however, the previous pairwise meta-analyses could not develop the hierarchy of these treatments. OBJECTIVES The purpose of the study is to perform a network meta-analysis to evaluate the clinical results of 7 surgical interventions for the treatment of lumbar disc herniation. STUDY DESIGN Network meta-analysis of randomized controlled trials (RCTs) for multiple treatment comparisons of lumbar disc herniation. METHODS We performed a Bayesian-framework network meta-analysis of RCTs to compare 7 surgical interventions for people with lumbar disc herniation. The eligible RCTs were identified by searching Embase, Pubmed, the Cochrane Central Register of Controlled Trials (CENTRAL), and Google scholar. Data from 3 outcomes (success, complications, and reoperation rate) were independently extracted by 2 authors. RESULTS A total of 29 RCTs including 3,146 participants were finally included into this article. Our meta-analysis provides hierarchies of these 7 interventions. For the success rate the rank probability (from best to worst): percutaneous endoscopic lumber discectomy (PELD) > standard open discectomy (SOD) > standard open microsurgical discectomy (SOMD) > chemonucleolysis (CN) > microendoscopic discectomy (MED) > percutaneous laser disc decompression (PLDD) > automated percutaneous lumber discectomy (APLD). For the complication rate the rank probability (from best to worst): PELD > SOMD > SOD > MED > PLDD > CN > APLD. For the reoperation rate the rank probability (from best to worst): SOMD > SOD > MED > PLDD > PELD > CN > APLD. LIMITATIONS The limitations of this network meta-analysis include the range of study populations and inconformity of the follow-up times and outcome measurements. CONCLUSIONS This meta-analysis provides evidence that PELD might be the best choice to increase the success rate and decrease the complication rate, moreover SOMD might be the best option to drop the reoperation rate. APLD might lead to the lowest success rate and the highest complication and reoperation rate. Higher quality RCTs and direct head to head trials are needed to confirm these results.Key words: Lumbar disc herniation, discectomy, minimally invasive surgery, network meta-analysis.