1. 2013;16;SE25-SE54An Update of the Systematic Assessment of Mechanical Lumbar Disc Decompression with Nucleoplasty
   Systematic Review
   Laxmaiah Manchikanti, MD, Frank J.E. Falco, MD, Ramsin M. Benyamin, MD, David L. Caraway, MD, Timothy R. Deer, MD, Vijay Singh, MD, Haroon Hameed, MD, and Joshua A. Hirsch, 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 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, although several alternative techniques are also utilized, including nucleoplasty, automated percutaneous discectomy  and laser discectomy. There is a paucity of evidence for all decompression techniques, specifically alternative techniques including nucleoplasty.
STUDY DESIGN: A systematic review of the literature of mechanical lumbar disc decompression with nucleoplasty.
OBJECTIVE: To determine the effectiveness and update the effectiveness of mechanical lumbar disc decompression with nucleoplasty.
METHODS: The available literature on mechanical lumbar disc decompression with nucleoplasty was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies.
The level of evidence was classified as good, fair, and limited or poor based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF).
Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to September 2012, and manual searches of the bibliographies of known primary and review articles.
OUTCOME MEASURES: Pain relief and functional improvement were the primary outcome measures. Other Outocome measures were improvement of psychological status, reduction in 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: For this systematic review, 37 studies were considered for inclusion. Of these, there was one randomized trial and 14 observational studies meeting inclusion criteria for methodological quality assessment.
Based on USPSTF criteria, the level of evidence for nucleoplasty is limited to fair in managing radicular pain due to contained disc herniation.
LIMITATIONS: A paucity of literature with randomized trials.
CONCLUSIONS: This systematic review illustrates limited to fair evidence for nucleoplasty in managing radicular pain due to contained disc herniation.