Physiotherapy interventions versus surgical interventions for patients with prolapsed lumbar intervertebral disc (PLID): A critical review

Parvin Akter; Md Nazmul Hassan; Mohammad Anwar Hossain

doi:10.4103/ijptr.ijptr_69_22

REVIEW ARTICLE

Year : 2023 | Volume : 5 | Issue : 1 | Page : 8-13

Physiotherapy interventions versus surgical interventions for patients with prolapsed lumbar intervertebral disc (PLID): A critical review

Parvin Akter, Md Nazmul Hassan, Mohammad Anwar Hossain
Department of Physiotherapy, Centre for the Rehabilitation of the Paralysed, Savar, Dhaka, Bangladesh

Date of Submission	24-Apr-2022
Date of Decision	29-Aug-2022
Date of Acceptance	05-Nov-2022
Date of Web Publication	11-Aug-2023

Correspondence Address:
Dr. Parvin Akter
Department of Physiotherapy, Centre for the Rehabilitation of the Paralysed, Savar, Dhaka
Bangladesh

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijptr.ijptr_69_22

Abstract

The most common predisposing factor for low back pain is a prolapsed lumber intervertebral disc. It is the most prevalent symptom in the modern population, albeit it was formerly the ancient curse of society, and it affects 80% of the population at some time in their lives. The goal of this study was to assess the efficacy of physiotherapy versus surgery for patients with prolapsed intervertebral disc. A thorough search of Medline, Embase, CINAHL, CENTRAL, and PEDro was done. Randomized control trial and prospective cohort study relevant to physiotherapy versus surgery, physiotherapy management alone, surgery among the lumbar disc herniation patients were included. Studies that were written in English and came out between 2006 and 2018 were enlisted using inclusion criteria. For screening, identified similar types of articles, avoid duplicate articles, and finally compare and contrast 5 articles. In the short-term, according to the majority of the articles, surgery was more beneficial than conservative treatment. However, there was no discernible difference between physiotherapy and surgery after a long period of observation, and the re-operation rate after surgery was 3%–20% within the first 1–2 years. Physiotherapy intervention had no adverse effects, whereas surgery had some adverse effects. In all circumstances, physiotherapy intervention is more effective than surgery. Physiotherapy interventions should be prescribed in a structured way.

Keywords: Critical review, Herniated disc disease, Outcome, Physiotherapy intervention, Surgical management

How to cite this article:
Akter P, Hassan MN, Hossain MA. Physiotherapy interventions versus surgical interventions for patients with prolapsed lumbar intervertebral disc (PLID): A critical review. Indian J Phys Ther Res 2023;5:8-13

How to cite this URL:
Akter P, Hassan MN, Hossain MA. Physiotherapy interventions versus surgical interventions for patients with prolapsed lumbar intervertebral disc (PLID): A critical review. Indian J Phys Ther Res [serial online] 2023 [cited 2023 Oct 1];5:8-13. Available from: https://www.ijptr.org/text.asp?2023/5/1/8/383681

Introduction

Prolapsed Lumbar Intervertebral Disc (PLID) is the most common predisposing factor for low back pain.^[1] It is the most common symptom in the modern population, though it was the ancient curse of society previously, and over 80% of the population are affected by this symptom at some point in their lives.^[2] It is the second most common factor for patients in search of primary care services that estimated over 70% of adults have at least one episode of low back pain (LBP) with or without radiating pain in their lifetime, though people of all ages suffer from low back pain.^[3] Globally, LBP is the number one cause of disability.^[4]

According to the National Center for Health Statistics in the United States, 14% of new patients who went to a hospital for treatment had low back pain, which translates to 13 million people, raising the cost of health care for adults with spinal disorders.^[5]

There are several predisposing factors for LBP. Some studies suggest that lower back region pain is generated due to disc degeneration, PLID, spondylolisthesis, lumbar stenosis, epidural hematoma, and so on.^[6] According to another study, lumbar disc herniation (LDH) recurrence is linked to sex (male), height, intensive work, and smoking. Males, young age, current smoking, higher body mass index, herniation type (transligamentous extrusion), surgical techniques (bilateral laminectomy or complete laminectomy), strenuous work, and traumatic events were identified to be the significant predictors for the recurrence of lumber herniation after discectomy in another study.^[7]

Physical therapy, pharmacological treatment, and infiltrations are examples of conservative treatments for symptomatic individuals. 90% of sciatica cases caused by LDH are resolved with conservative treatment.^[8]

Conservative treatment of LDH has a lower risk of complications than surgery, and conservative treatment (physiotherapy) is more beneficial than surgery in low-term follow-up, which is why the majority of patients prefer it.^[9]

Lumbar discectomy is the most common surgical intervention to treat prolapsed intervertebral discs.^[10] However, discectomy has an unsatisfactory outcome in 5%–20% of cases.^[11] Most people who have a discectomy still have problems today, and the most common reason is recurrent LDH, which happens in 5%–15% of cases and gets more common over time.^[12]

Therefore, the aim of this critical review is to compare the effects of physiotherapy exercise versus surgery for prolapsed lumbar intervertebral disc disease. Besides, the purpose of the study is to identify the pertinent article concerning physiotherapy exercise or surgery for patients having PLID or LDH.

This critical review was conducted using various databases such as Pedro, PubMed, CINHAL, Embase, MEDLINE, and various journals such as Spine Journal, Journal of Physiotherapy, Asian Spine Journal, European Spine journal, and Clinical Rehabilitation. In this review, the clinical question was developed using the PICO format. Randomized control trials and prospective cohort studies that compared physiotherapy to surgery, physiotherapy management alone, or surgery among the LDH patients were included. Studies that were written in English and came out between 2006 and 2018 were enlisted using inclusion criteria. There are no age or gender limitations for inclusion. After searching, 1015 articles were found from different databases. Then, 65 articles were recorded for screening. After that, articles were checked to see if they were eligible, and 20 articles were taken where the rest were thrown out because they had already been looked at. Finally, 5 articles were included for critical review.

[Table 1]"> Summary [Table 1]

Table 1: Summary of the articles included for critical review

Click here to view

A study with the title of “Laminotomy Discectomy Versus Conservative Management for Lumbar Disc Prolapse: Short-Term Results” was published in the journal Indian Journal of Orthopaedic Surgery. The study's objective was to look at the clinical signs and symptoms, assess the outcomes of both conservative and surgical treatments, and compare the outcomes of the two approaches. Of the 60 patients who participated in the study, 30 were treated conservatively and another 30 underwent laminotomy discectomy. Among the participants, 56.67% of the cases had disc prolapse at the L4L5 level, which is the most common site of disc prolapse, followed by L5-S1 with about 41.67% and 1.67% at the L3L4 level. Conservative intervention included complete bed rest with pelvic traction with weight around 8–10 kg followed by week to 10 days of gradual mobilization, drug therapy, lumbosacral corset, and braces. Exercises including McKenzie extension exercise, William's flexion exercise, and abdominal and spine flexor strengthening exercises are also recommended when acute pain decreases. After 1–2 weeks later when acute symptoms subside, passive exercises and short-wave diathermy, transcutaneous electrical nerve stimulation are recommended as physiotherapy for 2 weeks. The surgery group received preoperative preparation including antibiotics, surgery, and postoperative management, which included abdominal strengthening exercise. Patients were re-assessed 6 weeks, 3 months, and 6 months later. In the short-term follow-up of 6 months, the outcome of surgically treated patients was good at 90% and excellent at 6.67%, with a 3% complication rate. A conservatively treated group of patients showed 46.67% good, 43.33% fair, and 10% poor results. A good to excellent outcome was seen in nearly 97% in surgical study and in conservatively treated group, 90% of patients showed fair to good result. Therefore, this study concluded that both groups showed improvement, but surgery for disc herniation has better improvement during acute symptoms than conservative management.^[13]

Another study conducted with the title “Prolonged conservative care versus early surgery in patients with sciatica from LDH: Cost-utility analysis alongside a randomized controlled trial.” The study's goal was to see if the faster recovery from early sciatica surgery compared to long-term conservative treatment could be achieved at a reasonable cost. 283 participants participated in this study who had sciatica due to lumber herniation that lasted for 6–12 weeks. After randomization, participants were divided into two groups. Within 2 weeks after randomization, the surgery group received a unilateral transflaval approach using magnification. The conservative group received prolonged conservative care by a general practitioner. Participants in the conservative group received surgery (microdiscectomy) when conservative treatment did not give any satisfactory outcome and when it increased the symptoms. Compared with prolonged conservative care, early surgery provided faster recovery, with a gain in QALYs according to the UK EuroQol of 0.044 (95% confidence interval 0.005–0.083), the USEuroQol of 0.032 (0.005–0.059), the SF-6D of 0.024 (0.003–0.046), and the Visual Analog Scale of 0.032 (−0.003–0.066). Early surgery resulted in a faster recovery than long-term conservative therapy, according to the findings. However, from the hospital's view, early surgery resulted in a higher cost than prolonged care.^[14]

“Prolonged Physiotherapy versus Early Surgical Intervention in Patients with Lumbar Disk Herniation: Short-term Outcomes of Clinical Randomized Trial.” The purpose of this study was to compare the disability and functional result in individuals with LDH after conservative treatment with prolonged physiotherapy versus early surgical intervention. Sixty participants were randomly selected from June 2011 to July 2013. At first, all the participants received conservative care included activity modification; soft tissue massage; electrotherapy; static exercises for abdominal muscles, back muscles, and hip extensors; stretching exercises to the hamstring as well as range of motion exercises for 4 weeks and medication of muscle relaxants, analgesics, anti-inflammatory medication, pregabalin, and Vitamin B complex. However, 99 participants had no significant change in their symptoms compared to a 127 participants. Therefore, 60 participants agreed to consent to randomization into two groups. Group I continues the conservative treatment of medical and a prolonged physiotherapy program up to 6 months. Group II received lumber discectomy and also follow-up for 6 months. The results showed that significant improvement were found in both groups without statistically significant differences in the disability score at the second assessment (P = 0.06) and third assessment (P = 0.3). However, the mean Prolo scale score was significantly better in Group I than in Group II patients during the second (P = 0.03) and third (P = 0.05) assessments had significant improvement in disability and work status. Hence, prolonged physiotherapy is an advantageous and effective management procedure than surgical management for LDH.^[15]

“Surgical versus Nonoperative Treatment for Lumbar Disk Herniation: The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial.” The study's goal was to see how successful surgery was for lumbar intervertebral disc herniation. 501 participants were randomly assigned after taking consent from them. Among them, 245 were assigned to receive surgery and 256 were assigned for nonoperative treatment. Therefore, follow-up continue for 2 years. Within 6 weeks, a follow-up was taken, followed by 3 months, 6 months, 1 year, and 2 years later. The surgery group had an open discectomy with the assessment of the involved nerve root, while the other received standard care, which included at least active physical therapy, education or counseling, home exercise instruction, and nonsteroidal anti-inflammatory medicines. Results showed that both groups had significant improvement after 2 years' follow-up. For the secondary outcome of sciatica bothersomeness, showed that there were greater improvements in the Sciatica Bothersomeness Index in the surgery group with results of the global hypothesis test being statistically significant (P =0.003). Self-rated progress showed a small statistically significant advantage for surgery (P =0.04). However, large number of participants converted into two directions, that mean conservative group participants also received surgery within 2 years. Hence, the superiority of any treatment was not evaluated through intention-to-treat analysis.^[16]

Surgical versus nonoperative treatment for LDH: Four-year results for the SPORT. The study's goal was to compare the 4-year outcomes of surgery with nonoperative care. Large numbers of participants participated in this study. They were divided into two groups: A randomized group and an observational group. Then, in both groups, participants were again divided into surgical and nonsurgical groups. At the end of the 4-year follow-up, around 50% of the participants in both groups continue the follow-up. The surgical group had an open discectomy, whereas the nonoperative group received standard care, which included intensive physical therapy, education/counseling, and home exercise instruction, as well as nonsteroidal anti-inflammatory medicines if tolerated. In the 4-year combined as treated analysis, those receiving surgery demonstrated significantly greater improvement in all the primary outcome measures (mean change surgery vs. nonoperative; treatment effect; 95% CI): BP (45.6 vs. 30.7; 15.0; 11.8–18.1), PF (44.6 vs. 29.7; 14.9; 12.0–17.8), and ODI (−38.1 vs. −24.9; −13.2; −15.6 to − 10.9). The percentage working was similar between the surgery and nonoperative groups, 84.4% versus 78.4%, respectively .^[17]

Critiques

Article 1

This study has the good feature that they focused the percentage of results in a chronological way. They were assessed three times after the surgery about how the participants felt. Although they were assessed three times and the last follow-up was taken after 6 months of surgery, many articles focused on the fact that within 2 years of surgery, many patients need re-operation due to several causes. Previous studies focused that recurrent lumber disc herniation occurs after 1 year of surgery and the rate was 5%15%. The unsatisfactory outcome of primary surgery was 5%20%. The main causes of recurrent LDH were sex, smoking, and heavy work.^[11] The present article also focused on physiotherapy treatments as forms of passive exercise and electrotherapeutic modalities such as short-wave diathermy and TENS. They segregate the McKenzie method and strengthening exercises from physiotherapy. In this study, the conservative group had a moderately higher success rate in LDH than in the surgery. A previous systematic review said that the McKenzie method (direction preference) is a good way to treat low back pain and also a good way to predict how well things will go.^[18] This study did not find any big difference about physiotherapy after surgery. Therefore, we need a long-term follow-up to compare the conservative and surgical management of LDH to deliver a cost-effective service to our clients

Article 2

This study was conducted the study with more participants, though they did not mention the process of randomization. The age range is between 18 and 65 years, but a study suggested that age influences the provocation of symptoms. A study suggested that risk factors for recurrent LDH were age, gender, height, and overload.^[12] Prolonged conservative care is provided by a general practitioner, but this study did not mention the conservative treatment protocol or duration of receiving treatment. The most important thing is that this study clearly mentioned the surgical procedure. They had seen the cost-utility between surgery and conservative care. According to hospital views, surgery has a higher cost than conservative care. According to the study, a few complications develop after surgery, and the complication rate is around 3%.^[19] After surgery, patients need proper rehabilitation, and a study mentioned that early rehabilitation after lumber surgery is not only effective but also requires cost.^[20] Therefore, surgery is effective for LDH primarily but has complications and a chance of recurrent LDH or reoperation

Article 3

This study summarizes that for LDH, prolonged physiotherapy treatment is needed, and the duration is about 6 months of follow-up. This study clearly mentioned the randomization procedure and also focused on the dropout. A previous systematic review suggested that manual therapy had moderate to strong evidence in the management of LBP.^[21] Another systematic review clearly discussed the significance of conservative treatment (physiotherapy mainly) and suggested that for short-term follow-up, conservative treatment was less effective than microdiscectomy, but in long-term follow-up, physiotherapy was highly effective and stabilization exercise was more effective than no treatment. Manipulation was more effective whereas traction, ultrasound, and medical management had adverse effects.^[9] However, other studies focused on whether lumber surgery for LDH is effective, though recurrent LDH was predominant.^[19] Therefore, physiotherapy intervention has a better outcome in the management of LDH without any complications and recurrence than surgery and is also cost-effective.

Article 4

This is the only study which continues the follow-up for up to 2 years after surgery. Although this study mentioned that both groups had significant improvement after 2 years follow-up, both groups needed both directions such as conservative group received surgery within 2 years and the surgery group also needed reoperation. They were not clearly set up the conservative treatment protocol, whereas the study supported that physiotherapy intervention is effective for LDH and for long-term better benefit after surgery needs a comprehensive physiotherapy program.^[22] A study also suggested that the risk of reoperation rate varies from 5% to 12.5%, whereas due to recurrent LDH reoperation rate was 3%20%.^[23] Hence, to avoid complication and recurrent LDH, prolong physiotherapy is more effective than short-term beneficial surgery.

Article 5

This was the other study that looked at the outcome of surgery and nonoperative treatment for disc herniation for up to 4 years. This study suggested that surgery was more effective in the short-term than nonsurgical procedures, but in the long-term, there was no significant difference in relation to work. Another study also supported that long-term follow-up of 810 years of patients with spinal stenosis had no difference between surgery and nonoperative. It was also suggested that those who had more leg pain associated with back pain had more benefited from having undergone surgery initially.^[10]

Conclusion

After evaluation of the above-mentioned articles, it is concluded that physiotherapy intervention and surgery both are effective for the management of herniated disc disease. Although physiotherapy intervention has taken more time to reduce the symptoms of PLID than surgical management, physiotherapy had no adverse effect. On the other hand, surgery provides faster relief of symptoms but had some adverse effect and chance of recurrent the symptoms.

This study only analyses five articles based on surgery and physiotherapy management. However, the evidence is of very low quality because no differences were found between surgery and usual conservative care in any of the clinical outcomes after 1 and 2 years. Future studies should evaluate who benefits more from surgery and who from conservative care after follow-up with more articles. In addition, economic evaluations should analyze against increased cost and complication rate of surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Garg B, Nagraja UB, Jayaswal A. Microendoscopic versus open discectomy for lumbar disc herniation: A prospective randomised study. J Orthop Surg (Hong Kong) 2011;19:30-4.
2.	Hoy D, Brooks P, Blyth F, Buchbinder R. The Epidemiology of low back pain. Best Pract Res Clin Rheumatol 2010;24:769-81.
3.	Vasudevan JM, Smuck M, Fredericson M. Evaluation of the athlete with buttock pain. Curr Sports Med Rep 2012;11:35-42.
4.	Vos T, Allen C, Arora M, Barber RM, Bhutta ZA, Brown A, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2on015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016;388:1545-602.
5.	Shmagel A, Foley R, Ibrahim H. Epidemiology of chronic low back pain in US adults: Data from the 2009-2010 National Health and Nutrition Examination Survey. Arthritis Care Res (Hoboken) 2016;68:1688-94.
6.	Bartynski WS, Petropoulou KA. The MR imaging features and clinical correlates in low back pain-related syndromes. Magn Reson Imaging Clin N Am 2007;15:137-54, v.
7.	Li Z, Yang H, Liu M, Lu M, Chu J, Hou S, et al. Clinical characteristics and risk factors of recurrent lumbar disk herniation: A retrospective analysis of three hundred twenty-one cases. Spine (Phila Pa 1976) 2018;43:1463-9.
8.	Jacobs WC, van Tulder M, Arts M, Rubinstein SM, van Middelkoop M, Ostelo R, et al. Surgery versus conservative management of sciatica due to a lumbar herniated disc: A systematic review. Eur Spine J 2011;20:513-22.
9.	Hahne AJ, Ford JJ, McMeeken JM. Conservative management of lumbar disc herniation with associated radiculopathy: A systematic review. Spine (Phila Pa 1976) 2010;35:E488-504.
10.	Atlas SJ, Keller RB, Wu YA, Deyo RA, Singer DE. Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the Maine lumbar spine study. Spine (Phila Pa 1976) 2005;30:936-43.
11.	Shimia M, Babaei-Ghazani A, Sadat BE, Habibi B, Habibzadeh A. Risk factors of recurrent lumbar disk herniation. Asian J Neurosurg 2013;8:93-6. [PUBMED] [Full text]
12.	Cheng J, Wang H, Zheng W, Li C, Wang J, Zhang Z, et al. Reoperation after lumbar disc surgery in two hundred and seven patients. Int Orthop 2013;37:1511-7.
13.	Maruthi CV, Shivanna. Laminotomy discectomy versus conservative management for lumbar disc prolapse: Short term results. Indian J Orthop Surg 2016;2:102-9.
14.	Peul WC, van den Hout WB, Brand R, Thomeer RT, Koes BW, Leiden-The Hague Spine Intervention Prognostic Study Group. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: Two year results of a randomised controlled trial. BMJ 2008;336:1355-8.
15.	Abou-Elroos DA, El-Toukhy MA, Nageeb GS, Dawood EA, Abouhashem S. Prolonged physiotherapy versus early surgical intervention in patients with lumbar disk herniation: Short-term outcomes of clinical randomized trial. Asian Spine J 2017;11:531-7.
16.	Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Hanscom B, Skinner JS, et al. Surgical vs. nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT): A randomized trial. JAMA 2006;296:2441-50.
17.	Weinstein JN, Lurie JD, Tosteson TD, Tosteson AN, Blood EA, Abdu WA, et al. Surgical versus nonoperative treatment for lumbar disc herniation: Four-year results for the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976) 2008;33:2789-800.
18.	May S, Aina A. Centralization and directional preference: A systematic review. Man Ther 2012;17:497-506.
19.	Ahsan K, Najmus-Sakeb K, Hossain A, Khan SI, Awwal MA. Discectomy for primary and recurrent prolapse of lumbar intervertebral discs. J Orthop Surg (Hong Kong) 2012;20:7-10.
20.	Oosterhuis T, Ostelo RW, van Dongen JM, Peul WC, de Boer MR, Bosmans JE, et al. Early rehabilitation after lumbar disc surgery is not effective or cost-effective compared to no referral: A randomised trial and economic evaluation. J Physiother 2017;63:144-53.
21.	Hidalgo B, Detrembleur C, Hall T, Mahaudens P, Nielens H. The efficacy of manual therapy and exercise for different stages of non-specific low back pain: An update of systematic reviews. J Man Manip Ther 2014;22:59-74.
22.	Ebenbichler GR, Inschlag S, Pflüger V, Stemberger R, Wiesinger G, Novak K, et al. Twelve-year follow-up of a randomized controlled trial of comprehensive physiotherapy following disc herniation operation. Clin Rehabil 2015;29:548-60.
23.	Andersen SB, Smith EC, Støttrup C, Carreon LY, Andersen MO. Smoking is an independent risk factor of reoperation due to recurrent lumbar disc herniation. Global Spine J 2018;8:378-81.