LUMBAR DISC HERNIATION: A REVIEW OF SURGICAL AND CONSERVATIVE TREATMENT

Background: Lumbar disc herniation (LDH) is a degenerative disorder of the spinal column, characterized by nerve root compression, leading to low back pain, sciatica, leg pain, and numbness. Factors such as axial overload and inflammation contribute to its progression. Diagnosis is based on clinical tests and magnetic resonance imaging. The treatment of LDH can be performed either conservatively or surgically, aiming to relieve the symptoms of this comorbidity. Objectives: This study aimed to review and compare surgical and conservative treatments for lumbar disc herniation (LDH). Materials and Methods: We employed the PICO strategy (Patients, Intervention, Comparison, Outcomes) to formulate the main research question. A literature review included articles published between 2019 and 2024 from databases such as PubMed and the Virtual Health Library (BVS). Studies on surgical and conservative treatments for patients with LDH were selected. The review process followed PRISMA guidelines for article selection and analysis. Inclusion criteria focused on full-text and open-access studies. Duplicate articles were excluded using the online tool “Rayyan”. Results: After applying the inclusion and exclusion criteria, 11 articles were selected to compose this review. Overall, studies indicated that most patients treated conservatively achieved significant symptom relief. However, surgery remains recommended for patients with persistent pain or neurological symptoms unresponsive to conservative treatment. Regarding surgical approaches, procedures such as microdiscectomy and endoscopic discectomy demonstrated effectiveness, offering faster recovery and fewer complications compared to traditional open discectomy. Conclusion: While conservative treatment is highly effective for most LDH patients and serves as the first-line option, surgical intervention remains essential for severe cases. Minimally invasive surgical techniques improve clinical outcomes and reduce recovery time. LUMBAR DISC HERNIATION: A REVIEW OF SURGICAL AND CONSERVATIVE TREATMENT Marcus Vinícius Vieira Torquato 1, Társio Thiago Lopes Alves Filho 2, Douglas Mendes Soares 3, Pedro Vinicius Pompeu de Oliveira 4, Renan Castro Bandeira 5, Rômulo Pedroza Pinheiro 6 1 Email: [email protected] ; ORCID: 0009-0003-8329-112. Instituition: State University of Ceará

The author has nothing to report. Ethics Statement: Not applicable. Conflict of Interest Disclosures: The authors declare no conflicts of interest. | Keywords: Lumbar Disc Herniation Surgical Intervention Conservative Treatment Low Back Pain | Background: Lumbar disc herniation (LDH) is a degenerative disorder of the spinal column, characterized by nerve root compression, leading to low back pain, sciatica, leg pain, and numbness. Factors such as axial overload and inflammation contribute to its progression. Diagnosis is based on clinical tests and magnetic resonance imaging. The treatment of LDH can be performed either conservatively or surgically, aiming to relieve the symptoms of this comorbidity. Objectives: This study aimed to review and compare surgical and conservative treatments for lumbar disc herniation (LDH). Materials and Methods: We employed the PICO strategy (Patients, Intervention, Comparison, Outcomes) to formulate the main research question. A literature review included articles published between 2019 and 2024 from databases such as PubMed and the Virtual Health Library (BVS). Studies on surgical and conservative treatments for patients with LDH were selected. The review process followed PRISMA guidelines for article selection and analysis. Inclusion criteria focused on full-text and open-access studies. Duplicate articles were excluded using the online tool “Rayyan”. Results: After applying the inclusion and exclusion criteria, 11 articles were selected to compose this review. Overall, studies indicated that most patients treated conservatively achieved significant symptom relief. However, surgery remains recommended for patients with persistent pain or neurological symptoms unresponsive to conservative treatment. Regarding surgical approaches, procedures such as microdiscectomy and endoscopic discectomy demonstrated effectiveness, offering faster recovery and fewer complications compared to traditional open discectomy. Conclusion: While conservative treatment is highly effective for most LDH patients and serves as the first-line option, surgical intervention remains essential for severe cases. Minimally invasive surgical techniques improve clinical outcomes and reduce recovery time. | SUMMARY • Conservative treatment effective in ~90% of lumbar disc herniation cases. • Surgery is vital when pain or neurological deficits persist. • Minimally invasive surgery shortens recovery and reduces risks. • Treatment choice impacts global strategies for spinal care.

Lumbar disc herniation (LDH) is a degenerative disorder of the spinal column, frequently observed in the adult population (1,2) . The primary cause of LDH is the degeneration of the nucleus pulposus and the annulus fibrosus of the intervertebral disc, particularly when they compress the nerve root, leading to pain sensation (3) . The symptoms are described as low back pain, sciatica, leg pain, and numbness. Furthermore, LDH causes radiating pain due to the compression of nerve structures (4) . The role of inflammatory signaling has been recognized as an important process in intervertebral disc degeneration and may play a prominent role in pain generation (5) . Individuals with lumbar disc herniation exhibit elevated serum levels of tumor necrosis factor alpha (TNF-α) and interleukin-6 (IL-6) (6) . One of the main contributing factors to the development of lumbar disc herniation is axial overload, which is typically caused by a sedentary lifestyle and prolonged sitting, or through sports and self-reported incidents, such as heavy lifting. Additionally, genetic coefficients and vertebral abnormalities, such as scoliosis, are also associated with LDH. These factors can directly impact the quality of life of patients affected by lumbar disc herniation (5,7,8) . The diagnosis of LDH, clinical analyses are recommended, including manual muscle testing, sensory testing, and straight leg raise test. Magnetic resonance imaging (MRI) is the preferred study for diagnosing suspected LDH, due to its visualization of soft tissue and reported diagnostic accuracy of up to 97% (9) . The treatment of LDH can be performed either conservatively or surgically, aiming to relieve the symptoms of this comorbidity. Approximately 90% of patients with LDH have achieved good or excellent results with conservative treatment, both in clinical and radiological assessments (1,10) . However, cases that do not respond to this type of therapy are conventionally indicated for surgery (11,12) . The objective of this study is to analyze and compare surgical procedures with conservative techniques for the treatment of patients affected by lumbar disc herniation, based on the available evidence in the literature.

STUDY TYPE This study is a literature review, constructed through the following stages: identification of the topic and formulation of the guiding question; establishment of article selection criteria; data collection; interpretation of results; and presentation of the review. The aim of this methodological analysis is to produce a comprehensive, updated review and make it available in the scientific literature on the proposed topic (13) . STRUCTURE OF THE PICO STRATEGY To achieve the objective, the PICO strategy was used to formulate the guiding question. PICO is an acronym representing Patient ”P”, Intervention ”I”, Comparison ”C”, and Outcome ”O” (14) . In this context, for this study, the following was determined: P - patients affected by lumbar disc herniation; I - surgical treatment; C - conservative treatment; O - procedures performed and outcomes. Thus, the following guiding question was established: how do the procedures and outcomes of surgical treatment compare to conservative treatment in patients affected by lumbar disc herniation? Table 1 below demonstrates in a didactic manner how the guiding question was constructed. Table 1. Structuring the PICO Strategy | I | Surgical treatment | | C | Conservative treatment | | O | Procedures performed and outcomes | DATA COLLECTION The bibliographic survey was conducted in May 2024, using articles published in the US National Library of Medicine (PubMed) and the Virtual Health Library (VHL) databases. In the latter, only studies from the following portals were selected: Medical Literature Analysis and Retrieval System Online (MEDLINE) and Latin American and Caribbean Literature in Health Sciences (LILACS). The search was performed using terms from the Health Sciences Descriptors (DeCS/MeSH), which were: ”Disc Herniation”, ”Surgical Procedure”, and ”Conservative Treatment.” The descriptors were combined using the Boolean operator ”AND”. INCLUSION CRITERIA The following inclusion criteria were adopted: full-text and open-access studies, published between 2019 and 2024, addressing surgical and conservative treatments in patients affected by lumbar disc herniation. EXCLUSION CRITERIA Duplicate articles, those with content unrelated to the proposed topic and/or written in languages other than the selected ones, were excluded. Reviews of any category, theses, and dissertations were also excluded. Duplicate removal was performed using the online tool “Rayyan”.

Based on the search strategy and inclusion criteria, 126 articles were found. After the removal of 62 duplicates, 64 papers remained for title/abstract reading. Exclusion criteria were then applied, resulting in 26 studies for full-text review. After a comprehensive evaluation of the full texts and exclusion of works that did not address the topic, 11 articles were selected to compose this review. The article selection process followed the recommendations of the PRISMA flowchart (15), as depicted in Figure 1 . Figure 1. PRISMA flow diagram Table 2. Results Obtained | BASE | TITLE | AUTHOR AND YEAR | OBJECTIVE | CONCLUSIONS | | PubMED | Comparison of the effectiveness and outcome of microendoscopic and open discectomy in patients suffering from lumbar disc herniation (2) . | Yadav RI, Long L, Yanming C. | Comparative efficacy of microendoscopic lumbar discectomy versus open lumbar discectomy for lumbar disc herniation. | MED represents a safe and effective alternative to open discectomy for patients with lumbar disc herniation, requiring highly specialized skills and training for its optimal execution. | | PubMED | Lumbar disc herniation in a 15-year-old girl: A case report (7) . | Balafif F, Faris M, Subagio EA, Bajamal AH, Kusumadewi A. | Conduct a case study on the first reported instance of pediatric lumbar disc herniation in Indonesia. | LDH should be considered across all age groups so that a more accurate diagnosis and treatment plan can be followed to improve the patient’s quality of life. | | PubMED | Clinical and Radiological Follow-Up Results of Patients with Sequestered Lumbar Disc Herniation: A Prospective Cohort Study (10) . | Sucuoğlu H, Barut AY. | Evaluate the relationship between radiological changes and clinical outcomes in patients with sequestrated lumbar disc herniation (LDH). | Conservative treatment is recommended in the initial period for patients with sequestrated lumbar disc herniation (LDH) who do not have surgical indications. | | BVS (MEDLINE) | Clinical outcome of biportal endoscopic revisional lumbar discectomy for recurrent lumbar disc herniation (16) . | Kang MS, Hwang J, Choi DJ, Hun Jae Chung, Lee JH, Hyong Nyun Kim, et al. | Compare the outcomes of lumbar revision discectomy (RLD) using a biportal endoscopic technique (BE) and open microscopy (OM) in cases of recurrent lumbar disc herniation (RLDH). | The study suggested that BE-RLD is an alternative surgical option and yields clinical results similar to those of OM-RLD one year after surgery. However, faster pain relief and earlier functional recovery were observed in BE-RLD. | | BVS (MEDLINE) | Comparison of lumbar microdiscectomy and unilateral biportal endoscopic discectomy outcomes: a single-center experience (17) . | Mehmet İlker Özer, Oğuz Kağan Demirtaş. | A retrospective comparison was made between the results of lumbar microscopic discectomy (LMD), considered the gold standard, and the unilateral biportal endoscopic discectomy (UBE) technique for the treatment of lumbar disc herniations. | The reduction in lower back and leg pain was observed in both groups after 3 months, with no significant differences in the Visual Analog Scale (VAS) scores. The Oswestry Disability Index (ODI) score showed a significant variation between the groups in the postoperative period (p < 0.001), with more pronounced improvements in the LMD group. | | PubMED | Comparison of the Clinical Outcomes of Full-Endoscopic Visualized Foraminoplasty and Discectomy Versus Microdiscectomy for Lumbar Disc Herniation (18) . | Hua W, Ke W, Wang B, Xiang Q, Zhang Y, Wu X, et al. | Evaluate and compare the clinical outcomes of foraminoplasty and fully endoscopically visualized discectomy with microdiscectomy for lumbar disc herniation. | FEVFD and MD are reliable techniques for the treatment of symptomatic LDH. FEVFD resulted in faster recovery and equivalent clinical outcomes after 24 months of follow-up. | | PubMED | One-hole split endoscopy technique versus unilateral biportal edoscopy technique for L5-S1 lumbar disk herniations analysis of clinical and radiologic outcomes (19) . | Zhang Y, Feng B, Hu P, Dai G, Su W. | Clinical and radiological analysis between two techniques for the treatment of lumbar disc herniation. | Surgical procedures were successful in all patients studied. The OSE and UBE groups did not show statistically significant differences regarding age, sex, body mass index (BMI), lower limb symptoms, preoperative Visual Analog Scale (VAS) scores for lumbar region and leg pain, or Oswestry Disability Index (ODI). No significant differences were observed between the groups in terms of giant lumbar disc herniation (LDH), migrated LDH, or calcification cases. | | BVS (MEDLINE) | Postoperative Pain Management after Full Endoscopic Lumbar Discectomy: An Observational Study (20) . | Lin GX, Sun LW, Shang-Wun Jhang, Chen CM, Rui G, Hu BS. | To evaluate various postoperative pains that occur following total endoscopic lumbar discectomy. | Different types of postoperative pain have their own unique characteristics and durations. Most patients provided feedback about the pain from the surgical incision, which can be assessed by the patient themselves or with the appropriate use of analgesics, and its duration, typically lasting around 3 days. Approximately 5.8% of patients experienced recovery pain, with its level being equal to or less than preoperative pain, and it was alleviated by conservative treatment, sufficient bed rest, and analgesia. | | BVS (LILACS) | Sports practice after lumbar discectomy in non-professional athletes: a cross-sectional study / Prática esportiva após discectomia lombar em atletas não profissionais: estudo transversal / Práctica deportiva tras discectomía lumbar en atletas no profesionales: un estudio transversal (21) . | Kanas M, Astur N, Garcia LR, Oliveira LB, Campiolo RBR, Wajchenberg M, et al. | Analyze the sports recovery of non-professional athletes after surgical treatment for lumbar disc herniation. | Only 12.31% of the participants reported impaired sports performance after discectomy, while for the majority, performance was either unaffected or even improved after surgery. | | PubMED | Two-level percutaneous endoscopic lumbar discectomy for highly migrated upper lumbar disc herniation: A case report (22). | Wu XB, Li ZH, Yang YF, Gu X. | Conduct a case study on a patient who received a two-level PELD treatment. | Two-level PELD as a transforaminal approach can be a safe and effective procedure for highly migrated upper lumbar disc herniations. | | PubMED | Unilateral biportal endoscopy via two different approaches for upper lumbar disc herniation: a technical note (23). | Shao R, Du W, Zhang W, Cheng W, Zhu C, Liang J, Yue J, Pan H. | Investigate the clinical efficacy of the unilateral biportal endoscopy (UBE) technique in the treatment of upper lumbar disc herniation (ULDH). | The clinical effect of the UBE technique in the treatment of ULDH was reliable. Depending on the disease’s requirements, either the interlaminar approach or the paraspinal approach of the UBE technique was selected. This technique took into account the treatment’s effectiveness, achieved the goal of being minimally invasive, and did not require special instruments. Therefore, it has potential for clinical application. | CONSERVATIVE TREATMENT A prospective cohort study (10) analyzed a total of 98 patients with sequestrated lumbar disc herniation, treated either conservatively (66 patients) or surgically (32 patients) over a period of 6 months. However, 18 patients discontinued the evaluation. At the end of the follow-up period, approximately 89.1% of the patients showed partial or complete regression of the lumbar disc herniation with conservative treatment alone. SURGICAL TREATMENT Two studies (7,21) demonstrated that, in the face of controversial outcomes, cases with persistent pain and neurological impairment are conventionally indicated for surgery. The main surgical procedures performed in patients with lumbar disc herniation include open discectomy, endoscopic discectomy, and microdiscectomy. OPEN DISCECTOMY A randomized prospective study (2) compared two surgical procedures performed on 60 patients with lumbar disc herniation, divided into two groups: 30 patients underwent open discectomy, and the other 30 underwent microdiscectomy. The study concluded that open discectomy remains the standard treatment for disc herniation. However, this approach was associated with longer surgical time (p = 0.006), greater blood loss (p = 0.0001), and longer hospital stay (p = 0.0472) compared to microdiscectomy. It was concluded that minimally invasive procedures are continuously evolving in relation to conventional open discectomy. ENDOSCOPIC DISCECTOMY Four studies (16,19,20,23) presented classifications of the endoscopic discectomy technique, which can be performed through one or two portals, referred to as the uniportal or biportal technique, respectively. A retrospective study (19) evaluated 133 patients with lumbar disc herniation at L5-S1, of which 70 were treated with the uniportal technique and 63 with the biportal technique. The comparison between the two approaches showed no statistical significance regarding hospital stay (p = 0.147) and the rate of excellent-good outcomes (p = 0.783). However, there were statistically significant differences in operative time (p = 0.001), intraoperative blood loss (p < 0.001), and incision length (p < 0.001) between the groups. A case report (22) described a 60-year-old patient with lumbar disc herniation at L2-L3 who did not respond to conservative treatment, administered for 3 months, and was indicated for endoscopic discectomy. The surgical procedure was effective, resulting in complete pain remission, and magnetic resonance imaging showed no remnants of the nucleus pulposus after 1 year of follow-up. MICRODISCECTOMY A retrospective case-control study (18) analyzed 198 patients with lumbar disc herniation, of which 102 were treated with foraminoplasty and endoscopically visualized discectomy (FEVFD), and 96 were treated with microdiscectomy. The microdiscectomy group showed a shorter operative time (p = 0.003), but a longer postoperative hospital stay (p < 0.001) compared to the FEVFD group. In addition, a study (17) evaluated 93 patients with lumbar disc herniation indicated for surgical treatment, with 39 undergoing microdiscectomy (MD) and 54 undergoing unilateral biportal endoscopy. This study showed no statistical significance regarding lumbar and radicular pain in the postoperative period (p > 0.05). Thus, both positive and negative aspects of MD were observed in comparison to other minimally invasive procedures.

The treatment of lumbar disc herniation (LDH) is the primary approach for relieving severe low back pain, which can be performed either conservatively or surgically. The conservative approach is the first recommended measure for patients with LDH due to the high rate of spontaneous hernia regression and the possibility of non-invasive treatment (10) . This conservative intervention includes pharmacological therapy, with the use of nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and shockwave therapy (12,16) . The main signs and symptoms of lumbar disc herniation (LDH) may resolve without the need for surgical intervention, and in some patients, a reduction in the size of the herniation is observed on imaging. This phenomenon is known as spontaneous regression of the hernia, which can occur either partially or completely (24) . Conservative treatment is effective in approximately 90% of cases of lumbar disc herniation (LDH) (1,10) . However, in the presence of controversial outcomes, cases with persistent pain and neurological impairment are conventionally indicated for surgery (7,21) . Surgical interventions performed in patients with LDH include the following procedures: open discectomy, endoscopic discectomy, and microdiscectomy. The conventional surgery for LDH has been open discectomy, but recently, with advancements in technology, minimally invasive procedures have become increasingly utilized (2,23) . Traditional open surgeries involve a large working area and provide complete decompression and removal of the herniated portion of the nucleus pulposus. However, they carry a higher risk of structural damage to the spine. Open discectomy is performed through a longitudinal incision in the skin, usually between 3.5 and 5 centimeters (2) . From this incision, extensive resection of muscles, ligaments, fasciae, laminae, and facet joints is carried out to enucleate the herniated portion of the nucleus pulposus, which may result in iatrogenic instability, low back pain, and weakness following the surgical procedure (22,23) . Open discectomy is the standard procedure for the treatment of disc herniations. However, when compared to microdiscectomy, it is associated with longer operative time, increased blood loss, and a prolonged hospital stay (2) . As a result, there has been an evolution of minimally invasive techniques to address this clinical condition. Endoscopic discectomy (ED) is a minimally invasive and highly effective alternative for the treatment of lumbar disc herniation. This procedure is performed through the insertion of an endoscope via an incision of 8 to 10 millimeters to remove the herniated nucleus pulposus (22) . The technique can be performed through one or two portals, classified as uniportal or biportal, respectively (16,19,20,23) . Both demonstrate excellent hospital stay and excellent-good outcome rates. However, the uniportal technique is superior in terms of surgical time, intraoperative blood loss, and incision length, making it an advantageous option for improving clinical outcomes while maintaining results similar to the biportal approach (19) . Meanwhile, microdiscectomy (MD) is performed through a 3 to 4-centimeter incision, using microscopic magnification to remove the disc herniation (17) . When compared to endoscopic discectomy, it was equally effective in clinical aspects but showed a shorter surgical time and, conversely, a longer postoperative hospital stay (18) . However, when comparing microdiscectomy (MD) to the open discectomy technique, greater efficiency is observed in terms of surgical time and postoperative hospital stay, as well as reduced blood loss, faster return to daily activities, and less anesthetic exposure, highlighting the evolution of this minimally invasive method (2) .

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Authors Metrics & Citations Metrics Article Usage 463views 107downloads Citations Download citation Marcus Vinícius Vieira Torquato, Társio Thiago Lopes Alves Filho, Douglas Mendes Soares, et al. LUMBAR DISC HERNIATION: A REVIEW OF SURGICAL AND CONSERVATIVE TREATMENT. Authorea. 24 July 2025. DOI: https://doi.org/10.22541/au.175332625.54523706/v1 DOI: https://doi.org/10.22541/au.175332625.54523706/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu.