1. 2009;12;601-620Automated Percutaneous Lumbar Discectomy for the Contained Herniated Lumbar Disc: A Systematic Assessment of Evidence
   Systematic Review
   Joshua A. Hirsch, MD, Vijay Singh, MD, Frank J.E. Falco, MD, Ramsin M. Benyamin, MD, and Laxmaiah Manchikanti, MD.

BACKGROUND: Lumbar disc prolapse, protrusion, and 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 typical rationale for traditional surgery is an effort to provide more rapid relief of pain and disability. It should be noted that the majority of patients will recover with conservative management. The primary rationale for any form of surgery for disc prolapse associated with radicular pain 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 automated percutaneous lumbar discectomy (APLD) have been described. However, there is a paucity of evidence for all decompression techniques, specifically alternative techniques including automated and laser discectomy.

STUDY DESIGN: A systematic review of the literature.

OBECTIVE: To determine the effectiveness of APLD.

METHODS: A comprehensive evaluation of the literature relating to automated lumbar disc decompression 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.

A literature search was conducted of English language literature through PubMed, EMBASE, the Cochrane library, systematic reviews, and cross references from reviews and systematic reviews.
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).

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 indicated evidence for APLD is Level II-2 for short- and long-term relief.

LIMITATIONS: Paucity of RCTs in the literature.

CONCLUSION: This systematic review indicated Level II-2 evidence for APLD. APLD may provide appropriate relief in properly selected patients with contained lumbar disc prolapse.