Discectomy vs. sequestrectomy in the treatment of lumbar disc herniation: a systematic review and meta-analysis.

ABSTRACT

BACKGROUND CONTEXT Lumbar disc herniation (LDH) is one of the primary causes of low back pain (LBP) and leg pain and may require surgical treatment in case of persistent pain and/or neurological disturbances. Conventional discectomy consists of the removal of the herniated fragment and additional material from the disc space, potentially accelerating degeneration and causing chronic LBP. Conversely, by resecting the herniated fragment only, sequestrectomy may improve postoperative LBP while increasing the risk of LDH recurrence. PURPOSE: To compare the effects of discectomy vs. sequestrectomy in terms of risk of reherniation, reoperation rate, complications, pain, satisfaction, and perioperative outcomes (operative time, blood loss, length of stay [LOS]). STUDY DESIGN: Systematic review and meta-analysis. METHODS: A systematic search of PubMed/MEDLINE and Scopus databases was performed through May 1, 2024. Randomized and nonrandomized studies. The search was conducted according to PRISMA guidelines. The RoB-2 and MINORS tools were utilized to assess the risk of bias in included studies. The quality of the evidence was evaluated according to the GRADE approach. RESULTS: A total of 16 articles (1 randomized controlled trial with 2 follow-up studies, 6 prospective studies, and 7 retrospective studies) published between 1991 and 2020 including 2009 patients were included for analysis. No significant differences were noted between discectomy vs. sequestrectomy in terms of risk of reherniation (OR 0.85, 95% CI 0.57 to 1.26, p=0.42), reoperation rate (OR 0.95, 95% CI 0.64 to 1.40, p=0.78), and complications (OR 1.03, 95% CI 0.50 to 2.11). Although LBP (MD -0.06, 95% CI -0.39 to 0.28, p=0.74) and leg pain intensity (MD 0.11, 95% CI -0.21 to 0.42, p=0.50) was similar postoperatively, significantly better outcomes were reported by patients treated with sequestrectomy at 1 year (leg pain MD 0.37, 95% CI 0.19 to 0.54) and 2 years (LBP MD 0.19, 95% CI 0.03 to 0.34, p=0.02; leg pain MD 0.20, 95% CI 0.09 to 0.31, p=0.0005). Sequestrectomy also resulted in a higher patient satisfaction (OR 0.60, 95% CI 0.40 to 0.90, p=0.01) and shorter operative time (MD 8.71, 95% CI 1.66 to 15.75, p=0.02), while blood loss (MD 0.18, 95% CI -2.31 to 2.67, p=0.89) and LOS (MD 0.02 days, 95% CI -0.07 to 0.12, p=0.60) did not significantly differ compared to discectomy. CONCLUSIONS: Based on the current evidence, discectomy and sequestrectomy do not significantly differ in terms of risk of reherniation, reoperation rate, and postoperative complications. Patients treated with sequestrectomy may benefit from a marginally higher pain improvement, better satisfaction outcomes, and a shorter operative time, although the clinical relevance of these differences needs to be validated in larger, prospective, randomized studies.