Randomized controlled trial finds no advantage of tubular discectomy over microdiscectomy to treat sciatica

Patients with lumbar sciatica who underwent tubular discectomy, a technique introduced to improve surgical recovery rates, had slightly worse functional outcomes through the first postoperative year than those treated with microdiscectomy in a multicenter randomized controlled trial conducted in the Netherlands.

The double-blind study also found other outcomes were no better in the tubular discectomy group. “Patients who underwent tubular discectomy fared worse with regard to leg and back pain and fewer patients reported recovery at 1 year,” Mark P. Arts, MD, of the Medical Center Haaglanden, the Hague, the Netherlands, and colleagues noted in the study, which appears in the July 8 issue of the Journal of the American Medical Association.

Arts and colleagues included 328 patients between 18 and 70 years old with leg pain from a herniated lumbar disc lasting more than 8 weeks and presented for treatment at seven Dutch hospitals between January 2005 and October 2006. The patients were randomized to undergo tubular discectomy (167 patients) or conventional microdiscectomy (161 patients).

The techniques access the disc differently, either with a muscle retractor for microdiscectomy or transmuscularly with tubular discectomy. The latter involves placing tubular-shaped dilators of increasing diameter and a tubular retractor, which some clinicians consider gentler and to cause less tissue damage and pain.

Investigators used the Roland-Morris Disability Questionnaire (RDQ) as the primary functional outcome at 8 weeks and 1 year; higher scores mean more disability (range 0 – 23). Since 3 patients were excluded post-randomization and not all patients had complete data at 8 weeks and 1 year, investigators conducted an intent-to-treat analysis. It showed mean RDQ scores in the first year of 6.2 in the tubular discectomy group [95% CI, 5.6 to 6.8] and 5.4 in the microdiscectomy group [95% CI, 4.6 to 6.2].

At 8 weeks postop, mean RDQ scores were 5.8 and 4.9 for the tubular discectomy and microdiscectomy groups, respectively, with a mean between-group difference of 0.8 that reached 1.3 at 1 year postoperative, favoring microdiscectomy. One-year mean RDQ scores were 4.7 and 3.4 in the tubular discectomy and microdiscectomy groups, respectively.

Self-reported recovery at 1 year was good in 69% of tubular discectomy patients vs. 79% of microdiscectomy patients, investigators reported.

Reference:
Arts MP, Brand R, van den Akker MK, et al. Tubular discectomy vs conventional microdiscectomy for sciatica. JAMA. 2009;302(2):149-158.