1. 2009;12;561-572A Systematic Review of Mechanical Lumbar Disc Decompression with Nucleoplasty
   Systematic Review
   Richard Derby, MD, Ramsin M. Benyamin, MD, Laxmaiah Manchikanti, MD, Standiford Helm II, MD, and Joshua A. Hirsch, MD.

BACKGROUND: Lumbar disc prolapse, protrusion, or extrusion account for less than 5% of all low back problems, but are the most common causes of nerve root pain and surgical interventions. The primary rationale for any form of surgery for disc prolapse is to relieve nerve root irritation or compression due to herniated disc material. The primary modality of treatment continues to be either open or microdiscectomy, but several alternative techniques including nucleoplasty, automated percutaneous discectomy, and laser discectomy have been described. There is a paucity of evidence for all decompression techniques, specifically alternative techniques including nucleoplasty.

STUDY DESIGN: A systematic review of the literature.

OBJECTIVE: To determine the effectiveness of mechanical lumbar disc decompression with nucleoplasty.

METHODS: A comprehensive evaluation of the literature relating to mechanical lumbar disc decompression with nucleoplasty was performed. The literature was evaluated according to Cochrane review criteria for randomized controlled trials (RCTs), and Agency for Healthcare Research and Quality (AHRQ) criteria was utilized for observational studies.

The level of evidence was classified as Level I, II, or III with 3 subcategories in Level II based on the quality of evidence developed by the United States Preventive Services Task Force (USPSTF). A literature search was conducted using only English language literature through PubMed, EMBASE, the Cochrane library, systematic reviews, and cross-references from reviews and systematic reviews.

OUTCOME MEASURES: Pain relief was the primary outcome measure. Other outcome measures were functional improvement, improvement of psychological status, opioid intake, and return to work.

Short-term effectiveness was defined as one year or less, whereas, long-term effectiveness was defined as greater than one year.

RESULTS: Based on USPSTF criteria the level of evidence for nucleoplasty is Level II-3 in managing predominantly lower extremity pain due to contained disc herniation.

LIMITATIONS: Paucity of literature, both observational and randomized.

CONCLUSION: This systematic review illustrates Level II-3 evidence for mechanical lumbar percutaneous disc decompression with nucleoplasty in treatment of leg pain. However, there is no evidence available in managing axial low back pain.