Comparison of different treatments for lumbar disc herniation: a network meta-analysis and systematic review.

Background: Lumbar disc herniation (LDH) is a prevalent spinal disorder that imposes substantial health burdens in the form of chronic pain and mobility limitations, particularly in working-age populations. Due to advancements in technology and materials, the treatments for LDH are constantly being updated.

Purpose: The purpose of this systematic review and network meta-analysis (NMA) was to compare the outcomes of different LDH treatments.

Study design: A NMA of randomized controlled trials (RCTs) comparing various treatments for LDH.

Methods: This review was conducted in accordance with to the PRISMA-P guidelines. The PubMed, Embase, Medline, and Cochrane Library electronic databases were systematically searched from 2007 to March 2024 to identify RCTs comparing various treatments for LDH. The outcomes of interest included changes in the pain score, disability score and recurrence rate at the one-year follow-up. The risk of bias among the included studies was assessed using the Cochrane method. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was tailored for network meta-analysis and used to evaluate the overall certainty of the evidence regarding each outcome. This study employed a frequentist approach to conduct the NMA, and all procedures were carried out using the network package in Stata 14.2. The PROSPERO number was CRD42024578677.

Results: Twenty-seven RCTs involving 4633 participants and seven treatment strategies were included. Compared with conservative treatments, all surgical interventions demonstrated better efficacy in pain relief and disability recovery. Among the surgical options, endoscopic discectomy with internal fixation (EDF), percutaneous endoscopic discectomy (PED), microdiscectomy (MD) and open discectomy (OD) were found to be significantly superior to conservative treatments, with EDF showing the best performance. Surface under the cumulative ranking curve (SUCRA) plots displayed the same trend as the NMA results. No significant differences were observed in terms of recurrence rates. However, the SUCRA plots indicated that EDF ranked best in terms of recurrence rates. The GRADE assessment revealed that the quality of most of the evidence was low or very low.

Conclusion: The implantation of internal fixation devices was shown to have no impact on quality of life. EDF appears highly effective, especially for pain relief, but other less invasive options, such as PED, have similarly good outcomes in many respects.