Elsevier

The Spine Journal

Volume 14, Issue 1, 1 January 2014, Pages 180-191
The Spine Journal

Review Article
An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy

https://doi.org/10.1016/j.spinee.2013.08.003Get rights and content

Abstract

Background context

The objective of the North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy is to provide evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of lumbar disc herniation with radiculopathy. The guideline is intended to reflect contemporary treatment concepts for symptomatic lumbar disc herniation with radiculopathy as reflected in the highest quality clinical literature available on this subject as of July 2011. The goals of the guideline recommendations are to assist in delivering optimum efficacious treatment and functional recovery from this spinal disorder.

Purpose

To provide an evidence-based educational tool to assist spine specialists in the diagnosis and treatment of lumbar disc herniation with radiculopathy.

Study design

Systematic review and evidence-based clinical guideline.

Methods

This guideline is a product of the Lumbar Disc Herniation with Radiculopathy Work Group of NASS' Evidence-Based Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. A literature search addressing each question and using a specific search protocol was performed on English-language references found in Medline, Embase (Drugs and Pharmacology), and four additional evidence-based databases to identify articles. The relevant literature was then independently rated using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were developed via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Level I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.

Results

Twenty-nine clinical questions were formulated and addressed, and the answers are summarized in this article. The respective recommendations were graded by strength of the supporting literature, which was stratified by levels of evidence.

Conclusions

The clinical guideline has been created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients with symptomatic lumbar disc herniation with radiculopathy. The entire guideline document, including the evidentiary tables, suggestions for future research, and all the references, is available electronically on the NASS Web site at http://www.spine.org/Pages/PracticePolicy/ClinicalCare/ClinicalGuidlines/Default.aspx and will remain updated on a timely schedule.

Introduction

In an attempt to improve and evaluate the knowledge base concerning the diagnosis and treatment of lumbar disc herniation with radiculopathy, the Lumbar Disc Herniation with Radiculopathy Work Group of the North American Spine Society's (NASS) Evidence-Based Clinical Guideline Development Committee developed an evidence-based clinical guideline on this topic. The Institute of Medicine has defined a clinical guideline as “systematically developed statements to assist practitioner and patient decisions about health care for specific clinical situations” [1].

The application of the principles of evidence-based medicine (EBM) to guideline development helps to create an explicit linkage between the final recommendations in the guideline and the evidence on which these recommendations are based [2]. When employing the principles of EBM, the clinical literature is extensively searched to answer specific questions about a disease state or medical condition. The literature that is identified in the search is then rated as to its scientific merit using levels of evidence, determined by specific rule sets that apply to human clinical investigations. The specific questions asked are then answered using studies of the highest possible levels of evidence that have been obtained from the searches. As a final step, the answers to the clinical questions are reformulated as recommendations that are assigned grades of strength related to the best clinical evidence available at the time of answering each question. The intent of the grade of recommendation is to indicate the strength of the evidence used by the work group in answering the question asked.

Section snippets

Methods

For this clinical guideline, the guideline development process was broken down into 11 steps. In Step 1, guideline participants, trained in the principles of EBM, submitted a list of clinical questions focused on diagnosis and treatment of lumbar disc herniation with radiculopathy that the guideline should address. Step 2 consisted of assigning work group members to a set of clinical questions. Step 3 consisted of each group identifying appropriate search terms and parameters to direct the

Definition and natural history

Question 1: what is the best working definition of lumbar disc herniation with radiculopathy?

Localized displacement of disc material beyond the normal margins of the intervertebral disc space resulting in pain, weakness, or numbness in a myotomal or dermatomal distribution.

Work Group Consensus Statement

Question 2: what is the natural history of lumbar disc herniation with radiculopathy?

In the absence of reliable evidence relating to the natural history of lumbar disc herniation with

Discussion

This evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy has several functions. It is an educational tool for both clinicians and patients, and as such, this particular guideline is intended to assist practitioners who treat patients with lumbar disc herniation with radiculopathy. This guideline also serves to focus and rate the clinical data on this topic. An evidence-based guideline such as this allows a physician access to the best

Author disclosures:

DSK: Nothing to disclose. SWH: Nothing to disclose. JEE: Stock Ownership: Janus Biotherapeutics (E, Paid directly to institution). DKR: Board of Directors: NASS Board of Directors (Research Council Director) (None), Congress of Neurological Surgeons President Elect (None); Scientific Advisory Board/Other Office: Neurosurgical Research Foundation (None); Grants: AANS Spine Section Grant (D, Paid directly to institution/employer). JLB: Support for travel to meetings for the study or other

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