A checklist to evaluate a report of a nonpharmacological trial (CLEAR NPT) was developed using consensus. Supervised endurance exercise training compared to home training after first lumbar diskectomy: a clinical trial. Five-year outcome of surgical decompression of the lumbar spine without fusion Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. Return to Work/Work Retention Outcomes of a Functional Restoration Program: A Multi‐center, Prospective Study With a Comparison Group Surgery versus prolonged conservative treatment for sciatica. Epidural Steroid Following Discectomy for Herniated Lumbar Disc Reduces Neurological Impairment and Enhances Recovery: A Randomized Study With Two-Year Follow-up Physiotherapy-Based Rehabilitation Following Disc Herniation Operation: Results of a Randomized Clinical Trial The Effect of Early Isolated Lumbar Extension Exercise Program for Patients with Herniated Disc Undergoing Lumbar Discectomy Early neuromuscular customized training after surgery for lumbar disc herniation: a prospective controlled study Early active rehabilitation after surgery for lumbar disc herniation: A prospective, randomized study of psychometric assessment in 50 patients The effectiveness of exercise programmes after lumbar disc surgery: a randomized controlled study Postoperative Pain After Lumbar Disc Surgery: A Comparison Between Parenteral Ketorolac and Narcotics Full-Endoscopic Interlaminar and Transforaminal Lumbar Discectomy Versus Conventional Microsurgical Technique: A Prospective, Randomized, Controlled Study A prospective, randomised trial of immediate exercise following lumbar microdiscectomy: a preliminary study. The development of a screening instrument to select patients at risk of residual complaints after lumbar disc surgery. The immediate and long-term effects of exercise and patient education on physical, functional, and quality-of-life outcome measures after single-level lumbar microdiscectomy: a randomized controlled trial protocol Effects of aquatic backward locomotion exercise and progressive resistance exercise on lumbar extension strength in patients who have undergone lumbar diskectomy. Costs and quality of life for prehabilitation and early rehabilitation after surgery of the lumbar spine Return to work after surgery for lumbar disc herniation. A rehabilitation-oriented approach in insurance medicine. Randomized controlled trial of neural mobilization after spinal surgery. Clinic-based training in comparison to home-based training after first-time lumbar disc surgery: a randomised controlled trial Epidural steroids, postoperative morbidity, and recovery in patients undergoing microsurgical lumbar discectomy. Effectiveness of behavioral graded activity after first-time lumbar disc surgery: short term results of a randomized controlled trial Clinical Trial of Postoperative Dynamic Back Exercises After First Lumbar Discectomy Tubular diskectomy vs conventional microdiskectomy for sciatica: a randomized controlled trial. Prehabilitation and early rehabilitation after spinal surgery: randomized clinical trial Intensive Dynamic Back Exercises With or Without Hyperextension in Chronic Back Pain After Surgery for Lumbar Disc Protrusion: A Clinical Trial Transforaminal Posterolateral Endoscopic Discectomy With or Without the Combination of a Low-Dose Chymopapain: A Prospective Randomized Study in 280 Consecutive Cases A randomised controlled trial of post-operative rehabilitation after surgical decompression of the lumbar spine Results of Early Active Rehabilitation 5–7 Years After Surgical Treatment for Lumbar Disc Herniation Effects of home strength training and stretching versus stretching alone after lumbar disk surgery: a randomized study with a 1-year follow-up. Economic Evaluation of a Behavioral-Graded Activity Program Compared to Physical Therapy for Patients Following Lumbar Disc Surgery Efficacy of dynamic lumbar stabilization exercise in lumbar microdiscectomy. Early Aggressive Exercise for Postoperative Rehabilitation After Discectomy Behavioral Graded Activity Following First-Time Lumbar Disc Surgery: 1-Year Results of a Randomized Clinical Trial Are Postoperative Activity Restrictions Necessary After Posterior Lumbar Discectomy?: A Prospective Study of Outcomes in 50 Consecutive Cases Rehabilitation after surgery for lumbar disc herniation: Results of a randomized clinical trial Factors Predicting the Result of Surgery for Lumbar Intervertebral Disc Herniation Comparison of usual surgical advice versus a nonaggravating six-month gym-based exercise rehabilitation program post-lumbar discectomy: results at one-year follow-up. A randomized-control study of active and passive treatments for chronic low back pain following L5 laminectomy. Function After Spinal Treatment, Exercise, and Rehabilitation: Cost-Effectiveness Analysis Based on a Randomized Controlled Trial A new design for randomized clinical trials. Can Exercise Therapy Improve the Outcome of Microdiscectomy? Early Active Training After Lumbar Discectomy: A Prospective, Randomized, and Controlled Study Effects of training frequency on lumbar extension strength in patients recovering from lumbar dyscectomy. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomised trials Magnetic resonance imaging in follow-up assessment of sciatica. ISSLS Prize Winner: Function After Spinal Treatment, Exercise, and Rehabilitation (FASTER) A Factorial Randomized Trial to Determine Whether the Functional Outcome of Spinal Surgery Can Be Improved An Intensive, Progressive Exercise Program Reduces Disability and Improves Functional Performance in Patients After Single-Level Lumbar Microdiskectomy
BACKGROUND AND OBJECTIVE To develop a checklist of items measuring the quality of reports of r and omized clinical trials ( RCTs ) assessing nonpharmacological treatments ( NPTs ) . STUDY DESIGN AND SETTING The Delphi consensus method was used to select and reduce the number of items in the checklist . A total of 154 individuals were invited to participate : epidemiologists and statisticians involved in the field of methodology of RCTs ( n = 55 ) , members of the Cochrane Collaboration ( n = 41 ) , and clinicians involved in planning NPT clinical trials ( n = 58 ) . Participants ranked on a 10-point Likert scale whether an item should be included in the checklist . RESULTS Fifty-five experts ( 36 % ) participated in the survey . They were experienced in systematic review s ( 68 % were involved in the Cochrane Collaboration ) and in planning RCTs ( 76 % ) . Three rounds of the Delphi method were conducted to achieve consensus . The final checklist contains 10 items and 5 subitems , with items related to the st and ardization of the intervention , care provider influence , and additional measures to minimize the potential bias from lack of blinding of participants , care providers , and outcome assessors . CONCLUSIONS This tool can be used to critically appraise the medical literature , design NPT studies , and assess the quality of trial reports included in systematic review OBJECTIVE We performed a r and omised trial to evaluate if intensive supervised training of the back should be offered to all patients after a first lumbar diskectomy . METHODS Forty consecutive patients were , after a first lumbar diskectomy , r and omly allocated to 2 groups undergoing " supervised training " twice a week for 3 months in an outpatient clinic or " home training " after 2 hours of instruction . RESULTS The two rehabilitation models both showed a significant effect on spinal mobility , isokinetic trunk flexion strength , isokinetic trunk extension strength and daily function . These improvements were unchanged at follow up 3 months later . The pain score remained unchanged , however , throughout the trial in both groups . No differences in effect between the two rehabilitation models could be found for any of the assessed parameters . Thirteen patients did not complete the trial , including 9 from the supervised endurance trained group , mainly because of increased pain and reprolaps ( n = 4 ) . Four patients dropped out of the home trained group , only one because of increased pain . The differences in drop-out rate and training side effects were , however , not statistically significant . CONCLUSION We conclude that it is not worthwhile to implement 3 months of supervised intensive endurance training as opposed to home training in all cases of first lumbar diskectomy , although a beneficial effect and better compliance might be found for a selected group of such patients As the average life expectancy of the population increases , surgical decompression of the lumbar spine is being performed with increasing frequency . It now constitutes the most common type of lumbar spinal surgery in older patients . The present prospect i ve study examined the 5-year outcome of lumbar decompression surgery without fusion . The group comprised 159 patients undergoing decompression for degenerative spinal disorders who had been participants in a r and omised controlled trial of post-operative rehabilitation that had shown no between-group differences at 2 years . Leg pain and back pain intensity ( 0–10 graphic rating scale ) , self-rated disability ( Rol and Morris ) , global outcome of surgery ( 5-point Likert scale ) and re-operation rates were assessed 5 years post-operatively . Ten patients had died before the 5-year follow-up . Of the remaining 149 patients , 143 returned a 5-year follow-up ( FU ) question naire ( effective return rate excluding deaths , 96 % ) . Their mean age was 64 ( SD 11 ) years and 92/143 ( 64 % ) were men . In the 5-year follow-up period , 34/143 patients ( 24 % ) underwent re-operation ( 17 further decompressions , 17 fusions and 1 intradural drainage/debridement ) . In patients who were not re-operated , leg pain decreased significantly ( p < 0.05 ) from before surgery to 2 months FU , after which there was no significant change up to 5 years . Low back pain also decreased significantly by 2 months FU , but then showed a slight , but significant ( p < 0.05 ) , gradual increase of < 1 point by 5-year FU . Disability decreased significantly from pre-operative to 2 months FU and showed a further significant decrease at 5 months FU . Thereafter , it remained stable up to the 5-year FU . Pain and disability scores recorded after 5 years showed a significant correlation with those at earlier follow-ups ( r = 0.53–0.82 ; p < 0.05 ) . Patients who were re-operated at some stage over the 5-year period showed significantly worse final outcomes for leg pain and disability ( p < 0.05 ) . In conclusion , pain and disability showed minimal change in the 5-year period after surgery , but the re-operation rate was relatively high . Re-operation result ed in worse final outcomes in terms of leg pain and disability . At the 5-year follow-up , the “ average ” patient experienced frequent , but relatively low levels of , pain and moderate disability . This knowledge on the long-term outcome should be incorporated into the pre-operative patient information process CONTEXT Lumbar diskectomy is the most common surgical procedure performed for back and leg symptoms in US patients , but the efficacy of the procedure relative to nonoperative care remains controversial . OBJECTIVE To assess the efficacy of surgery for lumbar intervertebral disk herniation . DESIGN , SETTING , AND PATIENTS The Spine Patient Outcomes Research Trial , a r and omized clinical trial enrolling patients between March 2000 and November 2004 from 13 multidisciplinary spine clinics in 11 US states . Patients were 501 surgical c and i date s ( mean age , 42 years ; 42 % women ) with imaging-confirmed lumbar intervertebral disk herniation and persistent signs and symptoms of radiculopathy for at least 6 weeks . INTERVENTIONS St and ard open diskectomy vs nonoperative treatment individualized to the patient . MAIN OUTCOME MEASURES Primary outcomes were changes from baseline for the Medical Outcomes Study 36-item Short-Form Health Survey bodily pain and physical function scales and the modified Oswestry Disability Index ( American Academy of Orthopaedic Surgeons MODEMS version ) at 6 weeks , 3 months , 6 months , and 1 and 2 years from enrollment . Secondary outcomes included sciatica severity as measured by the Sciatica Bothersomeness Index , satisfaction with symptoms , self-reported improvement , and employment status . RESULTS Adherence to assigned treatment was limited : 50 % of patients assigned to surgery received surgery within 3 months of enrollment , while 30 % of those assigned to nonoperative treatment received surgery in the same period . Intent-to-treat analyses demonstrated substantial improvements for all primary and secondary outcomes in both treatment groups . Between-group differences in improvements were consistently in favor of surgery for all periods but were small and not statistically significant for the primary outcomes . CONCLUSIONS Patients in both the surgery and the nonoperative treatment groups improved substantially over a 2-year period . Because of the large numbers of patients who crossed over in both directions , conclusions about the superiority or equivalence of the treatments are not warranted based on the intent-to-treat analysis . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00000410 Study Design This was a study of a st and ardized functional restoration program that included 11 centers in saven states , involving 303 patients in the treatment group and 94 patients in the comparison group . Objective To illustrative the positive effect a functional restoration program has on return to work rates and work retention regardless of previous surgical intervention . Summary of Background Data Data were obtained from the initial and discharge evaluations as well as at 6− and 12-month follow-up . Methods Patients received a st and ardized work capacity assessment upon entrance and were recommended to the program if they adhered to specific entrance criteria . Treatment patients received the same evaluation at discharge . Results Significant improvement in functional abilities , actual return to work , and work retention were noted in the treatment group regardless of treatment intervention . Conclusions This study demonstrated improved return to work rates and work retention with surgical and nonsurgical patients after their participation in a functional restoration program BACKGROUND Lumbar-disk surgery often is performed in patients who have sciatica that does not resolve within 6 weeks , but the optimal timing of surgery is not known . METHODS We r and omly assigned 283 patients who had had severe sciatica for 6 to 12 weeks to early surgery  or to prolonged conservative treatment with surgery if needed . The primary outcomes were the score on the Rol and Disability Question naire , the score on the visual-analogue scale for leg pain , and the patient 's report of perceived recovery during the first year after r and omization . Repeated- measures analysis according to the intention-to-treat principle was used to estimate the outcome curves for both groups . RESULTS Of 141 patients assigned to undergo early surgery  , 125 ( 89 % ) underwent  microdiskectomy  after a mean of 2.2 weeks . Of 142 patients design ated for conservative treatment , 55 ( 39 % ) were treated surgically after a mean of 18.7 weeks . There was no significant overall difference in disability scores during the first year ( P=0.13 ) . Relief of leg pain was faster for patients assigned to early surgery ( P<0.001 ) . Patients assigned to early surgery also reported a faster rate of perceived recovery ( hazard ratio , 1.97 ; 95 % confidence interval , 1.72 to 2.22 ; P<0.001 ) . In both groups , however , the probability of perceived recovery after 1 year of follow-up was 95 % . CONCLUSIONS The 1-year outcomes were similar for patients assigned to early surgery and those assigned to conservative treatment with eventual surgery if needed , but the rates of pain relief and of perceived recovery were faster for those assigned to early surgery . ( Current Controlled Trials number , IS RCT N26872154 [ controlled-trials.com ] . ) Study Design . We r and omized 200 patients after lumbar discectomy to receive  epidural steroid or none with a 2-year follow-up . Objective . To evaluate the outcome , neurologic impairment and safety of epidural steroid following lumbar discectomy for herniated disc disease . Summary of Background Data . Convalescence after discectomy for herniated disc disease is dependent on pain and the inflammatory response . Previous studies in arthroscopic and abdominal surgery demonstrate steroids , which reduce the inflammatory response and enhance recovery . Here we report a 2-year follow-up of a r and omized trial of epidural steroid following lumbar discectomy . Methods . Through 2001 and 2003 200 patients undergoing discectomy for herniated disc disease were r and omly allocated to receive epidural methylprednisolone 40 mg or none . In the control group ( 62 males and 38 females , median age 41 years , 18–66 ) 48 L5 , 50 L4 , and 6 L3 discectomies were performed and in the intervention group ( 60 males and 40 females , median age 45 years , 15–53 ) 56 L5 , 46 L4 , and 3 L3 discectomies . Contemporary with r and omization to epidural steroid or none both groups received preoperative prophylactic antibiotics and the same multimodal pain treatment . Results . Hospital stay was reduced from 8 to 6 days ( P = 0.0001 ) and the number of patients with neurologic signs were reduced more ( 70 % vs. 44 % , P = 0.0004 ) by epidural steroid . Incidence of reoperation at 1 year was 6 % in both groups and 8 % in the control group and 7 % in the intervention group after 2 years . No infections were registered . Conclusion . Epidural methylprednisolone enhances recovery after discectomy for herniated disc disease without apparent side effects Study Design . Three-group , r and omized , single blinded , controlled trial . Objective . To test the effectiveness of physiotherapy-based rehabilitation starting 1 week after lumbar disc surgery . In addition , we tried to estimate the contribution of specific effects to the observed outcome ( efficacy ) . Summary of Background Data . Physiotherapy-based rehabilitation is usually recommended for patients following lumbar disc surgery . Few and conflicting data exist for the relative effectiveness of this intervention . Methods . A total of 120 patients following first-time , uncomplicated lumbar disc surgery were r and omly assigned to “ comprehensive ” physiotherapy , “ sham ” neck massage , or no therapy . Before enrollment , all subjects completed a minimal physiotherapeutic intervention . Physiotherapy was administered by experienced physiotherapists and consisted of 20 sessions per patient over 12 weeks . Masseurs administered “ sham massage ” to the neck . The amount of treatment time was equal to that of physiotherapy . The main outcome measure was the Low Back Pain Rating Score ( LBPRS ) at 6 and 12 weeks , and 1.5 years after r and omization . Secondary parameters were patients ' overall satisfaction with treatment outcome and socioeconomic and psychologic measures . Results . At the end of therapy ( 12 weeks ) , the LBPRS revealed a significantly better improvement in the physiotherapy group than in the untreated group . LBPRS outcome , however , did not significantly differ between physiotherapy and “ sham ” therapy . There was a tendency toward significance between the sham therapy and no therapy . Within the 1.5-year follow-up , LBP rating scales remained significantly improved compared with baseline , but there were no significant outcome differences . No statistically significant between-group differences were found for the secondary outcome parameters . Conclusion . As compared with no therapy , physiotherapy following first-time disc herniation operation is effective in the short-term . Because of the limited benefits of physiotherapy relative to “ sham ” therapy , it is open to question whether this treatment acts primarily physiologically in patients following first-time lumbar disc surgery , but psychological factors may contribute substantially to the benefits observed OBJECTIVE : To determine the effects of a postoperative early isolated lumbar extension muscle-strengthening program on pain , disability , return to work , and power of back muscle  after operation for herniated lumbar disc . METHODS : Seventy-five patients were r and omized into an exercise group  ( 20 men , 15 women ) and a control group ( 18 men , 22 women ) to perform a prospect i ve controlled trial of a lumbar extension exercise program in patients who underwent lumbar microdiscectomy or percutaneous endoscopic discectomy .  Six weeks after surgery , patients in the exercise group undertook a 12-week lumbar extension exercise program . The assessment included measures of lumbar extensor power by the MedX ( Ocala , FL ) lumbar extension machine , muscle mass of multifidus and longissimus ( L4–L5 cross-sectional area ) by computed tomography . All patients completed the visual analog scale and the Oswestry disability index to assess pain and disability , respectively . Return to work data were also investigated . RESULTS : After the exercise program , significant improvements were observed in the exercise group versus the control group for lumbar extensor power ( 51.67 % versus 17.55 % , respectively ; P < 0.05 ) , the cross-sectional area of multifidus and longissimus muscle ( 29.23 % versus 7.2 % , respectively ; P < 0.05 ) , and the visual analog scale score ( 2.51 versus 4.30 , respectively ; P < 0.05 ) . The percentages of returning to work within 4 months after surgery were significantly greater in the exercise group than in the control group ( 87 % versus 24 % , respectively ) . Although this was not statistically significant ( P > 0.05 ) , the Oswestry disability index scores in the exercise group were better than that in control group ( 24.6 versus 30.6 , respectively ) . CONCLUSION : These results support the positive effects of the postoperative early lumbar extension muscle-strengthening program on pain , return to work , and strength of back muscles in patients after operation of herniated lumbar disc A prospect i ve and controlled study of training after surgery for lumbar disc herniation ( LDH ) . The objective was to determine the effect of early neuromuscular customized training  after LDH surgery . No consensus exists on the type and timing of physical rehabilitation after LDH surgery . Patients aged 15–50 years , disc prolapse at L4–L5 or L5–S1 . Before surgery , at 6 weeks , 4 , and 12 months postoperatively , the following evaluations were performed : low back pain and leg pain estimated on a visual analog scale , disability according to the Rol and –Morris question naire ( RMQ ) and disability rating index ( DRI ) . Clinical examination , including the SLR test , was performed using a single blind method . Consumption of analgesics was registered . Twenty-five patients started neuromuscular customized training 2 weeks after surgery ( early training group = ETG ) . Thirty-one patients formed a control group ( CG ) and started traditional training after 6 weeks . There was no significant difference in pain and disability between the two training groups before surgery . Median preoperative leg pain was 63 mm in ETG and 70 mm in the CG . Preoperative median disability according to RMQ was 14 in the ETG and 14.5 in the CG . Disability according to DRI ( 33/56 patients ) was 5.3 in the ETG vs. 4.6 in the CG . At 6 weeks , 4 months , and 12 months , pain was significantly reduced in both groups , to the same extent . Disability scores were lower in the ETG at all follow-ups , and after 12 months , the difference was significant ( RMQ P=.034 , DRI P=.015 ) . The results of the present study show early neuromuscular customized training to have a superior effect on disability , with a significant difference compared to traditional training at a follow-up 12 months after surgery . No adverse effects of the early training were seen . A prospect i ve , r and omized study with a larger patient sample is warranted to ultimately demonstrate that early training as described is beneficial for patients undergoing LDH surgery In a r and omized study , using psychometric assessment , we evaluated two training programs before and after  surgical treatment  of lumbar disc herniation . 26 patients were treated according to an early active training program ( treatment group ) . 24 patients followed a traditional less active training program ( control group ) .  Before surgery , the patients filled in the following question naires 3 and 12 months after surgery : Multidimensional Pain Inventory ( MPI ) , State and Trait Anxiety Inventory , and Beck Depression Inventory . Pain was assessed by the patient 's pain drawing and a visual analog scale . Both groups improved as regards pain severity and state of anxiety . The MPI parameter , pain interference , improved more in the early active treatment group than in the control group . This suggests that the early active training program has a positive effect on the way patients cope with pain in their daily lives Objective : To compare two different exercise programmes versus a control group , after lumbar disc surgery . Design : A prospect i ve , single-blind , r and omized controlled study . Setting : Outpatient clinic of Istanbul Faculty of Medicine , Department of Physical Medicine and Rehabilitation . Subjects : Sixty patients diagnosed as having single level lumbar disc herniation with clinical examination and MRI evaluation and who had undergone lumbar discectomy ( post-operative first month ) at a single level . Patients with serious pathologies involving the cardiac and respiratory systems that could prevent them from doing exercises were excluded . Intervention : The patients were r and omly split into three groups . The first group received an intensive exercise programme and back school education while the second group received a home exercise programme and back school education . The third group was defined as the control group and did not receive education or exercise . Main measures : The patients were evaluated at the beginning and end of the treatment with clinical parameters , pain levels , endurance tests and weight-lifting tests , modified Oswestry Disability Index , Beck Depression Inventory , Low Back Pain Rating Scale and return to work . Results : The groups doing exercises experienced a decrease in the severity of pain and disability , also functional parameters showed better improvement than the control group . The intensive exercise programme was better than the home exercise programme . Conclusions : It seems that intensive exercise is more effective in reduction of pain and disability , but whether it is cost-effective is not clear Summary Objective . Lumbar discectomy is a common elective surgical procedure but many patients still experience postoperative back pain which may delay hospital discharge . We therefore evaluated the efficacy of a parenteral non-steroidal antiinflammatory agent , ketorolac , for the management of post-surgical pain . Methods . Fifty three patients undergoing lumbar discectomy at a Medical School affiliated Veterans Administration hospital were r and omly assigned to receive either : 1 ) 30 mg intramuscular ketorolac upon surgical closure and every 6 hours for 36 hours and narcotic analgesics as needed ( PRN ) ; or 2 ) only narcotic analgesics as needed . A blinded observer recorded the average , minimum and maximum postoperative pain intensity using a Numeric Pain Intensity Scale ; total postoperative narcotic consumption , complications , length of hospitalization ( from surgery to discharge ) and outcome at 6 weeks . Results . The patients who received ketorolac reported significantly lower average ( p<0.001 ) , minimum ( p<0.001 ) , and maximum ( p<0.001 ) pain scores than patients receiving only narcotic analgesics . Cumulative narcotic doses ( st and ardized to parenteral morphine ) were significantly lower in the ketorolac group ( p < 0.001 ) . There was no significant difference between groups in the frequency of side effects , and no complication specifically associated with ketorolac use was observed . Mean length of hospitalization was significantly shorter ( p=0.05 ) in patients receiving ketorolac than in patients receiving only narcotics . Six weeks after surgery 5 ( 19.2 % ) patients who received only narcotics were troubled by persistent back pain . By contrast , all patients who received ketorolac were free of back pain at follow-up ( p=0.03 ) . Conclusions . These results suggest that ketorolac , when used with PRN narcotics , is more effective than PRN narcotics alone for postoperative pain following lumbar disc surgery . In addition , this strategy also may contribute to early discharge from hospital after lumbar disc surgery Study Design . Prospect i ve , r and omized , controlled study of patients with lumbar disc herniations , operated either in a full-endoscopic or microsurgical technique .  Objective . Comparison of results of lumbar discectomies in full-endoscopic interlaminar and transforaminal technique with the conventional microsurgical technique . Summary of Background Data . Even with good results , conventional disc operations may result in subsequent damage due to trauma . Endoscopic techniques have become the st and ard in many areas because of the advantages they offer intraoperatively and after surgery . With the transforaminal and interlaminar techniques , 2 full-endoscopic procedures are available for lumbar disc operations . Methods . One hundred seventy-eight patients with full-endoscopic or microsurgical discectomy  underwent follow-up for 2 years . In addition to general and specific parameters , the following measuring instruments were used : VAS , German version North American Spine Society Instrument , Oswestry Low-Back Pain Disability Question naire . Results . After surgery 82 % of the patients no longer had leg pain , and 14 % had occasional pain . The clinical results were the same in both groups . The recurrence rate was 6.2 % with no difference between the groups . The full-endoscopic techniques brought significant advantages in the following areas : back pain , rehabilitation , complications , and traumatization . Conclusion . The clinical results of the full-endoscopic technique are equal to those of the microsurgical technique . At the same time , there are advantages in the operation technique and reduced traumatization . With the surgical devices and the possibility of selecting an interlaminar or posterolateral to lateral transforaminal procedure , lumbar disc herniations outside and insidethe spinal canal can be sufficiently removed using the full-endoscopic technique , when taking the appropriate criteria into account . Full-endoscopic surgery is a sufficient and safe supplementation and alternative to microsurgical procedures OBJECTIVE To investigate whether immediate commencement of exercises after lumbar microdiscectomy enabled patients to become independently mobile more rapidly with no increase in risk of complications . STUDY DESIGN R and omised , single-blind , controlled trial . SETTING One secondary care teaching hospital in the UK . PARTICIPANTS Thirty patients were recruited . The follow-up rate was 28 ( 93 % ) at 4 weeks and 23 ( 77 % ) at 3 months . INTERVENTIONS Patients were r and omised to an intervention group commencing exercises within 2 hours after surgery , or a control group commencing exercises on the first postoperative day . MAIN OUTCOME MEASURES Primary outcome measures included the time taken for the patient to become independently mobile and attain discharge criteria following surgery . Secondary outcome measures were disability and pain scores collected before surgery , and 4 weeks and 3 months after surgery ; and return to work rates . RESULTS The two groups were similar at baseline . The results indicated significantly reduced time to independent mobility [ median 7 vs 19 hours , median difference 9 hours , 95 % confidence interval ( CI ) 1.25 to 14.5 , P=0.009 ] and return to work ( median 6 vs 8 weeks , median difference 2 weeks , 95 % CI 0 to 6 , P=0.002 ) in the intervention group compared with the control group . At 15 hours after surgery , independent mobility was attained in 80 and 40 % of the intervention and control groups , respectively . There were no significant differences in disability and pain scores at 4 weeks and 3 months . CONCLUSIONS Immediate commencement of exercises following first-time single-level lumbar microdiscectomy enabled patients to become independently mobile more rapidly and return to work sooner . Immediate commencement of exercises may enable patients to be discharged earlier , with associated cost benefits to health care and no increase in the rate of revision surgery AIM A considerable number of patients who undergo surgery for a lumbosacral radicular syndrome ( LRS ) continue to experience disability , pain , and loss of work capacity . The goal of the study is to develop a brief screening instrument to identify these patients at risk of residual complaints . METHODS In a prospect i ve study of 277 patients , the predictors for the outcomes disability , pain , and loss of work capacity were investigated . The best predictive model was constructed using a stepwise selection procedure ( forward selection ) , which calculates the discriminative power of the model . Based on the relationship between regression coefficients , a clinical prediction rule was derived that predicted the probability of residual complaints after surgery for LRS . RESULTS At 6 month follow-up 141 patients ( 51 % ) had residual complaints . The discriminative power of the instrument was .78 ( AUC ) . The " Nijmegen Outcome of Lumbar Disc surgery Screening-instrument " ( NOLDS ) was based on the variables " lower education level " , " younger age " , " pain 3 days postoperatively " , " passive pain coping " , and " fear of movement/(re)injury " . CONCLUSION The results of the study are promising , showing that a brief clinical screening instrument can be used to identify patients at risk of residual complaints at 6 months after surgery for LRS . The early identification of patients at risk having residual complaints may make it possible to start tailored treatment early in the rehabilitation process Background Low back pain remains a costly quality -of-life-related health problem . Microdiscectomy is often the surgical procedure of choice for a symptomatic , single-level , lumbar disc herniation in younger and middle-aged adults . The question of whether a post-microdiscectomy exercise program enhances function , quality of life , and disability status has not been systematic ally explored . Thus , the overall purpose of this study is to assess immediate and long-term outcomes of an exercise program , developed at University of Southern California ( USC ) , targeting the trunk and lower extremities ( USC Spine Exercise Program ) for persons who have undergone a single-level microdiscectomy for the first time . Methods / design One hundred individuals between the ages of 18 and 60 who consent to undergo lumbar microdiscectomy will be recruited to participate in this study . Subjects will be r and omly assigned to one of two groups : 1 ) one session of back care education , or 2 ) a back care education session followed by the 12-week USC Spine Exercise Program . The outcome examiners ( evaluators ) , as well as the data managers , will be blinded to group allocation . Education will consist of a one-hour " one-on-one " session with the intervention therapist , guided by an educational booklet specifically design ed for post-microdiscectomy care . This session will occur four to six weeks after surgery . The USC Spine Exercise Program consists of two parts : back extensor strength and endurance , and mat and upright therapeutic exercises . This exercise program is goal -oriented , performance-based , and periodized . It will begin two to three days after the education session , and will occur three times a week for 12 weeks . Primary outcome measures include the Oswestry Disability Question naire , Rol and -Morris Disability Question naire , SF-36 ® quality of life assessment , Subjective Quality of Life Scale , 50-foot Walk , Repeated Sit-to-St and , and a modified Sorensen test . The outcome measures in the study will be assessed before and after the 12-week post-surgical intervention program . Long-term follow up assessment s will occur every six months beginning one year after surgery and ending five years after surgery . Immediate and long-term effects will be assessed using repeated measures multivariate analysis of variance ( MANOVA ) . If significant interactions are found , one-way ANOVAs will be performed followed by post-hoc testing to determine statistically significant pairwise comparisons . Discussion We have presented the rationale and design for a r and omized controlled trial evaluating the effectiveness of a treatment regimen  for people who have undergone a single-level lumbar microdiscectomy OBJECTIVE To compare the effects of aquatic backward locomotion exercise and progressive resistance exercise with a machine on lumbar extension strength in patients who have undergone diskectomy for a lumbar disk herniation . DESIGN Prospect i ve comparative study . SETTING Department of Kinesiology at a state university . PARTICIPANTS Male patients ( N=30 ) with disk herniation at spinal levels L3 to S1 completed this study as subjects . INTERVENTION After the diskectomy for a lumbar disk herniation , all patients had 6 weeks of rest time . At the end of the rest period , the aquatic backward locomotion exercise and progressive resistance exercise groups , respectively , started first 6 weeks of underwater training and lumbar extension training twice per week . After completion of the first 6-week training , subjects participated in a second 6-week training . After the whole 12-week training , subjects had no training for 6 weeks ( detraining ) and a follow-up 6-week training ( retraining ) . The control ( CON ) group did not undergo any training . MAIN OUTCOME MEASURES For each test , maximum voluntary isometric lumbar extension strength was measured in 7 trunk positions ( 72 degrees , 60 degrees , 48 degrees , 36 degrees , 24 degrees , 12 degrees , and 0 degrees of the trunk angle ) . RESULTS The progressive resistance exercise and aquatic backward locomotion exercise groups showed increases in lumbar extension strength after the first 6-week training , although they were not statistically different from the CON group . After a second 6-week training , the progressive resistance exercise and aquatic backward locomotion exercise groups showed statistically significant increases in their strength levels as compared with the CON group . After the detraining period , the strength levels of the progressive resistance exercise and aquatic backward locomotion exercise groups did not statistically differ from the CON group . After the retraining period , the progressive resistance exercise and aquatic backward locomotion exercise groups showed increases in their strength levels , which were different from that of the CON group . CONCLUSIONS The results obtained suggested that the aquatic backward locomotion exercise is as beneficial as progressive resistance exercise for improving lumbar extension strength in patients after lumbar diskectomy surgery Abstract During the recent years improved operation techniques and administrative procedures have been developed for early rehabilitation . At the same time preoperative lifestyle intervention ( prehabilitation ) has revealed a large potential for additional risk reduction . The aim was to assess the quality of life and to estimate the cost-effectiveness of st and ard care versus an integrated programme including prehabilitation and early rehabilitation . Methods The analyses were based on the results from 60 patients undergoing lumbar fusion for degenerative lumbar disease ; 28 patients were r and omised to the integrated programme and 32 to the st and ard care programme .  Data on cost and health related quality of life was collected preoperatively , during hospitalisation and postoperatively . The cost was estimated from multiplication of the re source consumption and price per unit . Results Overall there was no difference in health related quality of life scores . The patients from the integrated programme obtained their postoperative milestones sooner , returned to work and soaked less primary care after discharge . The integrated programme was 1,625 € ( direct costs 494 € + indirect costs 1,131 € ) less costly per patient compared to the st and ard care programme . Conclusion The integrated programme of prehabilitation and early rehabilitation in spine surgery is more cost-effective compared to st and ard care programme alone STUDY DESIGN An intervention study by the medical advisers of a social security sickness fund  on a m and atorily insured patient population after open discectomy for herniated lumbar intervertebral disc . The medical advisers were r and omized into two groups : a control group ( n = 30 ) and an intervention group ( n = 30 ) . OBJECTIVES To compare a rehabilitation-oriented approach in insurance medicine focused primarily on early mobilization and early resumption of professional activities with the usual cl aim -based practice . SUMMARY OF BACKGROUND DATA This study included 710 patients , with a mean age of 39.2 years , who underwent surgery for herniated lumbar disc . METHODS Medical advisers in the rehabilitation-oriented group examined the patients monthly , starting at 6 weeks after the surgical intervention . They used a newly developed protocol to motivate the patients and treating physicians toward social and professional reintegration . RESULTS At 52 weeks , 10.1 % of the patients guided by medical advisers from the rehabilitation-oriented group had not resumed work in contrast to 18.1 % of the patients in the control group . It was statistically proven that this effect also holds during the follow-up period . CONCLUSIONS A rehabilitation-oriented approach by the medical advisers of social security can increase the probability of a return to work for patients after lumbar disc herniation surgery STUDY DESIGN R and omized controlled trial with 12-month follow-up . OBJECTIVES To determine whether the addition of neural mobilization to st and ard postoperative care improved the outcome of lumbar spinal surgery . SUMMARY OF BACKGROUND DATA It has been suggested that neural mobilization should be performed after spinal surgery to prevent nerve root adhesions and improve outcome . However , to date , there is no convincing evidence of the value of neural mobilization . METHODS Eighty-one patients undergoing lumbar discectomy , fusion , or laminectomy at a private hospital in Sydney were r and omly allocated to st and ard postoperative care or st and ard care plus neural mobilization . Neural mobilization included passive movements and active exercises design ed to mobilize the lumbosacral nerve roots and sciatic tract . Primary outcome measures were global perceived effect measured on a 7-point scale , pain measured using visual analogue scales and the McGill Pain Question naire , and disability measured with the Quebec Disability Scale . RESULTS All patients received the treatment as allocated with 12-month follow-up data available for 76 patients ( 94 % of those r and omized ) . There were no statistically significant or clinical ly significant benefits provided by the neural mobilization treatment for any outcome . CONCLUSIONS The neural mobilization protocol evaluated in this study did not provide an additional benefit to st and ard postoperative care for patients undergoing spinal surgery . The authors advocate that this protocol not be used in clinical practice The effectiveness of physiotherapy after first-time lumbar disc surgery is still largely unknown . Studies in this field are heterogeneous and behavioural treatment principles have only been evaluated in one earlier study . The aim of this r and omised study was to compare clinic-based physiotherapy with a behavioural approach to a home-based training programme regarding back disability , activity level , behavioural aspects , pain and global health measures . A total of 59 lumbar disc patients without any previous spine surgery or comorbidity participated in the study . Clinic-based physiotherapy with a behavioural approach was compared to home-based training 3 and 12 months after surgery . Additionally , the home training group was followed up 3 months after surgery by a structured telephone interview evaluating adherence to the exercise programme . Outcome measures were : Oswestry Disability Index ( ODI ) , physical activity level , kinesiophobia , coping , pain , quality of life and patient satisfaction . Treatment compliance was high in both groups . There were no differences between the two groups regarding back pain disability measured by ODI 3 and 12 months after surgery . However , back pain reduction and increase in quality of life were significantly higher in the home-based training group . The patients in the clinic-based training group had significantly higher activity levels 12 months after surgery and were significantly more satisfied with physiotherapy care 3 months after surgery compared to the home-based training group . Rehabilitation after first-time lumbar disc surgery can be based on home training as long as the patients receive both careful instructions from a physiotherapist and strategies for active pain coping , and have access to the physiotherapist if questions regarding training arise . This might be a convenient treatment arrangement for most patients Intraoperative epidural corticosteroids have been used by some surgeons to decrease pain following surgery for a herniated lumbar disc . In this study , 84 consecutively treated , comparable patients with unilateral lumbar disc herniation were prospect ively assigned r and omly to receive either epidural corticosteroids ( 40 mg methylprednisolone acetate ) or saline at the conclusion of the operative procedure . The postoperative morbidity of these two groups was evaluated by tabulating the following parameters : pain relief as measured by consumption of postoperative pain medications ; the length of hospital stay ; postoperative functional status ; and the time interval from surgery until return to work . The mean postoperative analgesic medications consumed was 12.2 + /- 1.9 mg of morphine equivalents in the corticosteroid group versus 12.2 + /- 1.8 mg of morphine equivalents in the control group . The mean hospital stay was less than 2 days in each group , and the mean interval until return to work was 21.2 + /- 2.7 days in the corticosteroid group versus 25.4 + /- 3.1 days in the control group . Moreover , no statistically significant difference was measured between the steroid-treated and control groups when the data were stratified for sex , age , and site of disc herniation . The mean outcome scores , which are derived from a postoperative assessment of pain relief result ing from surgery , functional status , and interval until return to work , were identical in the corticosteroid and control groups . This study concludes that epidural corticosteroid administration after microsurgical lumbar discectomy for unilateral disc herniation does not lessen postoperative morbidity or improve functional recovery Behavioral approaches to treating patients following lumbar disc surgery are becoming increasingly popular . The treatment method is based on the assumption that pain and pain disability are not only influenced by somatic pathology , if found , but also by psychological and social factors . A recent study highlighted the effectiveness of cognitive-behavioral interventions , as compared to no treatment , for chronic low back patients . However , to the authors ' knowledge , there is no r and omized controlled trial that evaluates a behavioral program for patients following lumbar disc surgery . The purpose of this study was to assess the effectiveness of a behavioral grade d activity ( BGA ) program compared to usual care ( UC ) in physiotherapy following first-time lumbar disc surgery . The BGA program was a patient-tailored intervention based upon operant therapy . The essence of the BGA is to teach patients that it is safe to increase activity levels . The study was design ed as a r and omized controlled trial . Assessment s were carried out before and after treatment by an observer blinded to treatment allocation . Patients suffering residual symptoms restricting their activities of daily living and /or work at the 6 weeks post-surgery consultation by the neurosurgeon were included . The exclusion criteria were : complications during surgery , any relevant underlying pathology , and any contraindication to physiotherapy or the BGA program . Primary outcome measures were the patient 's Global Perceived Effect and the functional status . Secondary measures were : fear of movement , viewing pain as extremely threatening , pain , severity of the main complaint , range of motion , and relapses . Physiotherapists in the BGA group received proper training . Between November 1997 and December 1999 , 105 patients were r and omized ; 53 into the UC group and 52 into the BGA group . The unadjusted analysis shows a 19.3 % ( 95 % CI : 0.1 to 38.5 ) statistically significant difference to the advantage of the UC group on Global Perceived Effect . This result , however , is not robust , as the adjusted analyses reveal a difference of 15.7 % ( 95 % CI : −3.9 to 35.2 ) , which is not statistically significant . For all other outcome measures there were no statistically significant or clinical ly relevant differences between the two intervention groups . In general , the physiotherapists ' compliance with the BGA program was satisfactory , although not all treatments , either in the BGA or the UC group , were delivered exactly as planned , result ing in less contrast between the two interventions than had been planned for . There was one re-operation in each group . The BGA program was not more effective than UC in patients following first-time lumbar disc surgery . For Global Perceived Effect there was a borderline statistically significant difference to the advantage of the UC group . On functional status and all other outcome measures there were no relevant differences between interventions . The number of re-operations was negligible , indicating that it is safe to exercise after first-time disc surgery Ninety-six patients who had undergone first-time discectomy for herniated lumbar intervertebral discs were consecutively r and omized to two physical rehabilitation programs : a program of high-intensity , dynamic back extension and abdominal exercises with occurrence of low back pain being the limiting factor or a traditional program of mild , generally mobilityimproving exercises within pain limits . Both groups underwent 14 hours of treatment during a 6-week period 5 weeks after surgery . At 26 weeks ' follow-up , results indicated that patients who did the high-intensity exercises experienced greater success with regard to the patient disabilityindex and work capabilities . After 1 year , a trend that favored the use of intensive exercises could be observed . No differences were found in pain or objective measurements . A rehabilitation program of intensive exercises with occurrence of back pain being the limiting factor appears to increase patient behavioral support , result ing in work capacity improvements and patient self-rated disability levels . The results indicate that a 6-wk , 14-hr postoperative rehabilitation program is inadequate if objective postoperative deficit improvements are the desired goal CONTEXT Conventional microdiskectomy is the most frequently performed surgery for patients with sciatica due to lumbar disk herniation .  Transmuscular tubular diskectomy has been introduced to increase the rate of recovery , although evidence is lacking of its efficacy . OBJECTIVE To determine outcomes and time to recovery in patients treated with tubular diskectomy compared with conventional microdiskectomy .  DESIGN , SETTING , AND PATIENTS The Sciatica Micro-Endoscopic Diskectomy r and omized controlled trial was conducted among 328 patients aged 18 to 70 years who had persistent leg pain ( > 8 weeks ) due to lumbar disk herniations at 7 general hospitals in The Netherl and s from January 2005 to October 2006 . Patients and observers were blinded during the follow-up , which ended 1 year after final enrollment . INTERVENTIONS Tubular diskectomy ( n = 167 ) vs conventional microdiskectomy ( n = 161 ) . MAIN OUTCOME MEASURES The primary outcome was functional assessment on the Rol and -Morris Disability Question naire ( RDQ ) for sciatica ( score range : 0 - 23 , with higher scores indicating worse functional status ) at 8 weeks and 1 year after r and omization . Secondary outcomes were scores on the visual analog scale for leg pain and back pain ( score range : 0 - 100 mm ) and patient 's self-report of recovery ( measured on a Likert 7-point scale ) . RESULTS Based on intention-to-treat analysis , the mean RDQ score during the first year after surgery was 6.2 ( 95 % confidence interval [ CI ] , 5.6 to 6.8 ) for tubular diskectomy and 5.4 ( 95 % CI , 4.6 to 6.2 ) for conventional microdiskectomy ( between-group mean difference , 0.8 ; 95 % CI , -0.2 to 1.7 ) . At 8 weeks after surgery , the RDQ mean ( SE ) score was 5.8 ( 0.4 ) for tubular diskectomy and 4.9 ( 0.5 ) for conventional microdiskectomy ( between-group mean difference , 0.8 ; 95 % CI , -0.4 to 2.1 ) . At 1 year , the RDQ mean ( SE ) score was 4.7 ( 0.5 ) for tubular diskectomy and 3.4 ( 0.5 ) for conventional microdiskectomy ( between-group mean difference , 1.3 ; 95 % CI , 0.03 to 2.6 ) in favor of conventional microdiskectomy . On the visual analog scale , the 1-year between-group mean difference in improvement was 4.2 mm ( 95 % CI , 0.9 to 7.5 mm ) for leg pain and 3.5 mm ( 95 % CI , 0.1 to 6.9 mm ) for back pain in favor of conventional microdiskectomy . At 1 year , 107 of 156 patients ( 69 % ) assigned to tubular diskectomy reported a good recovery vs 120 of 151 patients ( 79 % ) assigned to conventional microdiskectomy ( odds ratio , 0.59 [ 95 % CI , 0.35 to 0.99 ] ; P = .05 ) . CONCLUSIONS Use of tubular diskectomy compared with conventional microdiskectomy did not result in a statistically significant improvement in the Rol and -Morris Disability Question naire score . Tubular diskectomy result ed in less favorable results for patient self-reported leg pain , back pain , and recovery . TRIAL REGISTRATION is rct n.org Identifier : IS RCT N51857546 Objective : To evaluate the outcome after spinal surgery when adding prehabilitation to the early rehabilitation . Design : A r and omized clinical study . Setting : Orthopaedic surgery department . Subject : Sixty patients scheduled for surgery followed by inpatient rehabilitation for degenerative lumbar disease . Interventions : The patients were computer r and omized to prehabilitation and early rehabilitation ( 28 patients ) or to st and ard care exclusively ( 32 patients ) . The intervention began two months prior to the operation . The prehabilitation included an intensive exercise programme and optimization of the analgesic treatment . Protein drinks were given the day before surgery . The early postoperative rehabilitation included balanced pain therapy with self-administered epidural analgesia , doubled intensified mobilization and protein supplements . Main measures : The outcome measurements were postoperative stay , complications , functionality , pain and satisfaction . Results : At operation the intervention group had improved function , assessed by Rol and Morris Question naire ( P = 0.001 ) . After surgery the intervention group reached the recovery milestones faster than the control group ( 1—6 days versus 3—13 , P = 0.001 ) , and left hospital earlier ( 5 ( 3—9 ) versus 7 ( 5—15 ) days , P = 0.007 ) . There was no difference in postoperative complications , adverse events , low back pain and radiating pain , timed up and go , sit-to-st and or in life quality . Patient satisfaction was significantly higher in the intervention group compared with the control group . Conclusion : The integrated programme of prehabilitation and early rehabilitation improved the outcome and shortened the hospital stay — without more complications , pain or dissatisfaction Sixty-two patients with chronic low back pain occurring 14 - 60 months after undergoing discectomy for the first time were r and omized to two physical treatment groups : 24 sessions of intensive dynamic back exercises with hyperextension or 24 sessions of intensive dynamic back exercises without hyperextension . At the conclusion of therapy and at one-year follow-up , no difference was seen between the r and omized groups , with regard to the combined assessment s of pain , disability and objective measurements . A difference for back exercises without hyperextension to be superior to the other treatment regimen was statistically significant at the three-month follow-up . In the patient 's qualitative assessment of treatment outcome there were seen no significant differences between back exercises with or without hyperextension .  There was a similar and significant improvement of the isometric endurance of back muscles in both groups , but the flexibility of the spine was significantly improved only in the group using hyperextension exercises . The overall response rate of an earlier published investigation was reproduced . It is concluded that chronic back patients after first time discectomy may benefit from an intensive rehabilitation protocol including intensive exercises . The added use of hyperextension exercises does not confer any independent benefit . Furthermore , the training had to continue for more than 2 - 3 months before a statistical significant decrease in back pain was reported in the patient pain diary Study Design . A prospect i ve r and omized study involving 280 consecutive cases of lumbar disc herniation managed either by an endoscopic discectomy alone or an endoscopic discectomy combined with an intradiscal injection of a low dose ( 1000 U ) of chymopapain . Objective . To compare outcome , complications , and reherniations of both techniques . Summary of Background Data . Despite a low complication rate , posterolateral endoscopic nucleotomy has made a lengthy evolution because of an assumed limited indication . Chemonucleolysis , however , proven to be safe and effective , has not continued to be accepted by the majority in the spinal community as microdiscectomy is considered to be more reliable . Method . A total of 280 consecutive patients with a primary herniated , including sequestrated , lumbar disc with predominant leg pain , was r and omized . A clinical follow-up was performed at 3 months , and at 1 and 2 years after the index operation with an extensive question naire , including the visual analog scale for pain and the MacNab criteria . The cohort integrity at 3 months was 100 % , at 1 year 96 % , and at 2 years 92 % . Results . At the 3-month evaluation , only minor complications were registered . At 1-year postoperatively , group 1 ( endoscopy alone ) had a recurrence rate of 6.9 % compared to group 2 ( the combination therapy ) , with a recurrence rate of 1.6 % , which was a statistically significant difference in favor of the combination therapy ( P = 0045 ) . At the 2-year follow-up , group 1 reported that 85.4 % had an excellent or good result , 6.9 % a fair result , and 7.7 % were not satisfied . At the 2-year follow-up , group 2 reported that 93.3 % had an excellent or good result , 2.5 % a fair result , and 4.2 % were not satisfied . This outcome was statistically significant in favor of the group including chymopapain . There were no infections or patients with any form of permanent iatrogenic nerve damage , and no patients had a major complication . Conclusions . A high percentage of patient satisfaction could be obtained with a posterior lateral endoscopic discectomy for lumbar disc herniation , and a statistically significant improvement of the results was obtained when an intradiscal injection of 1000 U of chymopapain was added . There was a low recurrence rate with no major complications . The method can be applied in any type of lumbar disc herniation , including the L5−S1 level Spinal decompression is the most common type of spinal surgery carried out in the older patient , and is being performed with increasing frequency . Physiotherapy ( rehabilitation ) is often prescribed after surgery , although its benefits compared with no formal rehabilitation have yet to be demonstrated in r and omised control trials . The aim of this r and omised controlled trial was to examine the effects on outcome up to 2 years after spinal decompression surgery of two types of postoperative physiotherapy compared with no postoperative therapy ( self-management ) .  Hundred and fifty-nine patients ( 100 men , 59 women ; 65 ± 11 years ) undergoing decompression surgery for spinal stenosis/herniated disc were r and omised to one of the following programmes beginning 2 months post-op : recommended to “ keep active ” ( CONTROL ; n = 54 ) ; physiotherapy , spine stabilisation exercises ( PT-StabEx ; n = 56 ) ; physiotherapy , mixed techniques ( PT-Mixed ; n = 49 ) . Both PT programmes involved 2 × 30 min sessions/week for up to 12 weeks , with home exercises . Pain intensity ( 0–10 graphic rating scale , for back and leg pain separately ) and self-rated disability ( Rol and Morris ) were assessed before surgery , before and after the rehabilitation phase ( approx . 2 and 5 months post-op ) , and at 12 and 24 months after the operation . ‘ Intention to treat ’ analyses were used . At 24 months , 151 patients returned question naires ( effective return rate , excluding 4 deaths , 97 % ) . Significant reductions in leg and back pain and self-rated disability were recorded after surgery ( P < 0.05 ) . Pain showed no further changes in any group up to 24 months later , whereas disability declined further during the “ rehabilitation ” phase ( P < 0.05 ) then stabilised , but with no significant group differences . 12 weeks of post-operative physiotherapy did not influence the course of change in pain or disability up to 24 months after decompression surgery . Advising patients to keep active by carrying out the type of physical activities that they most enjoy appears to be just as good as administering a supervised rehabilitation program , and at no cost to the health-care provider A prospect i ve and r and omized study was conducted of 52 patients who were treated by two home training programs after surgical treatment of lumbar disc herniation . Twenty-six patients followed an early active treatment program , and 26 patients followed a less active training program ( control group )  . Forty-nine patients ( 82 % ) answered a question naire 5–7 years postoperatively . The reoperation rate was two of 49 patients . None of these patients had followed the early active treatment program . Patients with signs of depression before surgery were not significantly less satisfied with the outcome than patients with no signs of depression before surgery OBJECTIVE To assess the adherence to and effects of a 12-month combined strength and stretching home exercise regimen versus stretching alone , on patient outcome after lumbar disk surgery . DESIGN R and omized controlled trial . SETTING Departments of physical medicine and rehabilitation and orthopedics at a Finnish hospital . PARTICIPANTS Patients ( N=126 ) were r and omized into either a combined strength training and stretching group ( STG , n=65 ) or a control group ( CG , n=61 ) . INTERVENTION The STG was instructed to perform strength training and both the STG and CG were instructed in the same stretching and stabilization exercises for 12 months . MAIN OUTCOME MEASURES Pain on the visual analog scale ( VAS ) , the Oswestry and the Million disability indexes , isometric and dynamic trunk muscle strength , mobility in the lumbar spine , and straight-leg raising were measured . RESULTS The trial was completed by 71 % and 77 % of the patients from the STG and the CG , respectively . The mean strength training frequency decreased from 1.5 to 0.6 times a week in the STG during the intervention . The mean stretching frequency decreased from 3.7 to 1.6 times a week in both groups . Median back and leg pain varied between 17 and 23 mm ( VAS ) , and the Million and Oswestry indices varied between 14 and 23 points 2 months postoperatively . No statistically significant changes took place in these outcome measures during the 12-month follow-up in both groups . The changes in isometric trunk extension favored the STG ( P = .016 ) during the first 2 months . However , during the whole 12-month training period , both dynamic and isometric back extension and flexion strength , as well as mobility of the spine and repetitive squat-test results , improved significantly in both groups , and no differences were found in any of the physical function parameters between the STG and CG . CONCLUSIONS At the 12-month follow-up , no statistically significant changes were found in the physical function , pain , or disability measures between the groups . In the STG , training adherence with regard to training frequency and intensity remained too low to lead to specific training-induced adaptations in the neuromuscular system . Progressive loading , supervision of training , and psychosocial support is needed in long-term rehabilitation programs to maintain patient motivation Study Design . An economic evaluation was conducted alongside a r and omized controlled trial . Summary of Background Data . Little is known about the effectiveness of cognitive-behavioral treatment options for patients following lumbar disc surgery . If the knowledge available was supported by an economic evaluation , the information could then be used to make recommendations for the implementation of cognitive-behavioral treatment in the routine of rehabilitation following lumbar disc surgery . Objective . To examine the cost-effectiveness of a behavioral- grade d activity program , which is an operant treatment , compared to usual care as delivered by a physical therapist for patients following first-time lumbar disc surgery . Methods . For the economic evaluation , a societal viewpoint was applied . The primary outcome measures ( measured at the 12-month follow-up ) were global perceived effect and functional status . To evaluate the economic consequences of the treatments , direct health care and non-health care costs were considered , as well as indirect costs . Results . The clinical outcomes showed no relevant differences between behavioral- grade d activity ( n = 52 ) and UC ( n = 53 ) . Treatment costs were almost identical in the two intervention groups . The difference in direct health care costs was , although not statistically significant , 264 EURO [ 95 % CI : −3–525 ] higher in behavioral- grade d activity than in usual care per patient-year . It was mainly the excess cost of visiting the physiotherapist in the behavioral- grade d activity group that accounted for this difference . The difference in direct non-health care costs , although not statistically significant , was 388 EURO [ 95 % CI : −217 ; 992 ] lower in the usual care group due to unpaid help by friends or family . Consequently , although again not statistically significant , the total direct costs  in behavioral- grade d activity are 639 EURO [ 95 % CI : −91 ; 1368 ] higherthan in usual care . For the indirect costs , there was a statistically significant difference , behavioral- grade d activity being more expensive . The sensitivity analysis showed that these results are fairly robust . Conclusions . This study concludes that there are no differences between the two treatment conditions on any of the clinical outcome measures but that behavioral- grade d activity is associated with higher costs . Consequently , there is no reason for the implementation of behavioral- grade d activity as the st and ard treatment for patients following lumbar disc surgery OBJECTIVE The aim of this study was to determine the efficacy of dynamic lumbar stabilization exercises in patients with lumbar microdiscectomy . DESIGN A prospect i ve , r and omized , controlled study . SUBJECTS Forty-two patients who were diagnosed as having lumbar disc herniation and had been operated on using the microdiscectomy method were divided r and omly into 3 groups . METHODS Dynamic lumbar stabilization exercises were set for the first group and a home exercise programme for the second . The third group given no exercises was considered as a control group . All patients were examined twice , once before the exercise programme and once 8 weeks later . RESULTS Improvement in the first group was highly significant after the treatment ( p < 0.0001 ) . The second group improved significantly more in some parameters ( pain , functional disability , lumbar Schober , progressive isoinertial lifting evaluation ( neck ) , trunk endurance ( flexion-extension ) ) than did the third group . The third group of patients showed some improvement in fingertip-floor distance , functional disability , modified lumbar Schober and left rotation in 8 weeks , but there were no significant improvements in the other parameters . CONCLUSION Dynamic lumbar stabilization exercises are an efficient and useful technique in the rehabilitation of patients who have undergone microdiscectomy . They relieve pain , improve functional parameters and strengthen trunk , abdominal and low back muscles Study Design . A r and omized clinical trial of postoperative medical exercise therapy in patients after operation for lumbar disc herniation with blind assessment of clinical outcomes . Objective . To assess the effect of an early regimen of vigorous medical exercise compared with an ordinary care program . Summary of Background Data . Methods . Patients offered an operation for lumbar disc herniation were consecutively r and omized to a training group or to a control group . The training consisted of an 8-week active rehabilitation program including a regimen of vigorous lumbar stabilizing exercises . The control subjects participated in a mild program of 2 to 3 back exercises at home , after relaxing and resting their backs for 2 months after the surgery . The outcomes were evaluated 6 and 12 months after the operation . The results are based on intention-to-treat analyses . Results . Sixty-three of 65 eligible patients agreed to participate in the trial . Fifty-eight and 53 patients attended for evaluation at 6 and 12 months , respectively . There was a significantly larger improvement in the mean Rol and ’s disability index ( from 8.9 to 5.4 [ P = 0.02 ] at 6 months and from 8.7 to 5.3 [ P = 0.03 ] at 12 months ) and in reported pain ( from 3.7 to 2.0 [ P = 0.04 ] at 6 months and from 3.2 to 1.8 [ P = 0.09 ] at 12 months ) in the training group . A significantly ( P = 0.05 ) higher proportion of the training group reported that they participated in daily activities as usual . There were more patients in the training group who reported improvement in self-evaluated health after surgery at both 6 ( P = 0.02 ) and at 12 months ( P = 0.05 ) . Finally , no differences in clinical end points were observed between the groups . Conclusions . Vigorous medical exercise therapy , started 4 weeks after surgery for lumbar disc herniation , reduced disability and pain after surgery . Because no differences in clinical end points were observed , there is hardly any danger associated with early and vigorous training after operation for disc herniation Study Design and Objectives . In a r and omized clinical trial , the effectiveness of behavioral grade d activity was assessed as compared to usual care provided by physiotherapists for patients after first-time lumbar disc surgery ( n = 105 ) . Summary of Background Data . Little is known about the effectiveness of rehabilitation programs following lumbar disc surgery . Most programs focus on biomechanical aspects , whereas psychosocial factors are hardly addressed . The aim of the behavioral grade d activity program , which is an operant treatment , is to alter psycho-social factors such as fear of movement and pain catastrophizing , which might subsequently lead to improved functional status and higher rates of recovery . Behavioral treatments for patients following lumbar disc surgery have not yet been assessed in a r and omized clinical trial . Methods . Inclusion criteria : age between 18 and 65 years ; first-time lumbar disc surgery ; restrictions in normal activities of daily living . Exclusion criteria : surgical complications and confirmed and relevant underlying diseases . Outcome assessment took place at 6 and 12 months after r and omization . Results . Six months after r and omization , 62 % of the patients had recovered following usual care versus 65 % of the patients following behavioral grade d activity . After 12 months , 73 % and 75 % , respectively , had recovered . Differences between intervention groups , 3 % and 2 % respectively , after 6 and 12 months are not statistically significant . Furthermore , there were no differences between the two groups regarding functional status , pain , pain catastrophizing , fear of movement , range of motion , general health , social functioning or return to work . After 1 year , 4 of the behavioral grade d activity cases had undergone another operation versus 2 of usual care cases . Conclusion . Both fear of movement and pain catastrophizing seem to be unaffected by either treatment in these patients . It is concluded that treatment principles derived from theories within the field of chronic low back pain might not apply to these patients . After 1 year of follow-up , there were no statistically significant or clinical ly relevant differences between the behavioral grade d activity program and usual care as provided by physiotherapists for patients following first-time lumbar disc surgery Study Design A prospect i ve clinical trial was conducted . Objectives To determine if removing activity restrictions after surgery and encouraging early return to work would affect clinical outcomes after lumbar discectomy . Summary of Background Information Current practice usually recommends several weeks to months of restricted activities after lumbar discectomy . No formal studies have been done to determine the optimal period of restriction , if any , after surgery . Methods Fifty consecutive patients undergoing limited open discectomy for herniated lumbar intervertebral disc were prospect ively treated with no restrictions at all after surgery and were urged to return to full activities as soon as possible . The patients were followed for a minimum of 2 years . At follow‐up evaluation , an independent examiner evaluated each patient . Results The mean time from surgery to return to work was 1.7 weeks . Eleven of 44 ( 25 % ) patients returned to work on the next work day . Ninety‐seven percent of patients who were working before surgery returned to their previous work . Forty‐three of 44 ( 97 % ) patients had returned to full duty by 8 weeks after surgery . At follow‐up evaluation ( 3.8 years ) , five patients had changed work ; three patients increased their work level , and two decreased their work level . No patient changed employment because of back or leg pain . There were three reherniations at the operative level ( 6 % ) , all occurring more than 1 year after surgery . One patent required reoperation . Back and leg pain scores at follow‐up evaluation were very low . Conclusion Lifting of postoperative restrictions after limited discectomy allowed shortened sick leave without increased complications . Postoperative pre caution s in these patients may not be necessary The aim of this prospect i ve study was to examine the one-year postoperative results in patients operated on for lumbar disc herniation r and omized in two groups : one with comprehensive rehabilitation and the other taken care of by normal care facilities . A total of 212 patients without any previous spinal operations comprised the final study group . The physiatrist , the surgeon , the social worker , and the psychologist performed the  h and icap evaluation  according to the occupation h and icap scales of the WHO . The h and icap was evaluated for two phases : before the onset of acute sciatica leading to operation and one year after operation . No significant differences in h and icap distribution between the intervention and normal care groups were seen . The postoperative h and icap correlated highly significantly with preoperative h and icap for both groups . More than half ( 57 % ) of all the patients returned to work within two months of the operation . The amount of sick leaves did not differ significantly between the intervention and normal care groups . A total of 15 persons ( 7 % ) retired during the postoperative year The prospect i ve study was undertaken to find out preoperative or perioperative factors predicting the results of the first surgery for lumbar disc herniation . The results were evaluated 1 and 6 months postoperatively using , in addition to the patient evaluation , indices for pain , activities of daily living ( ADL ) , and working capacity . The best result was achieved if the patient was operated on before 2 months ' duration of disabling sciatica . The operative finding grade d as protrusion predicted poor result . The social and psychological factors influenced the outcome more than the findings in the preoperative physical examination or the grade of operative finding . It is recommended to add indices for pain and ADL and a psychological test to the preoperative examinations of patients with lumbar disc herniation BACKGROUND CONTEXT Discectomy is the surgery of choice for the lumbosacral radicular syndrome . Previous studies on the postsurgical management of these cases compare one exercise regime to another . This study compares an  exercise-based group  with a control group involving no formal exercise or rehabilitation . PURPOSE The outcomes of a formal postsurgical exercise-based rehabilitation when compared with the usual rehabilitative surgical advice were evaluated . STUDY DESIGN A r and omized clinical trial comparing management regimes after lumbar discectomies . PATIENT SAMPLE Ninety-three lumbar discectomy patients were r and omized to two groups . OUTCOME MEASURES The following postoperative outcomes were used : levels of pain ; levels of function ; psychological well-being ; time off work ; levels of medication ; and number of doctor/therapist visits . METHODS Ninety-three lumbar discectomy patients were r and omized to two groups . The treatment group undertook a 6-month supervised nonaggravating exercise program . The control group followed the usual surgical advice to resume normal activities as soon as the pain allowed . Both groups were followed for 1 year by using vali date d outcome measures . RESULTS The results are based on an intention-to-treat analysis . Patients in both groups improved during the 1-year follow-up ( p=.001 ) . There was no statistical significance between the groups at the clinical endpoint . The treatment group returned to work 7 days earlier and had fewer days off work in the 1-year follow-up period . CONCLUSION There was no statistical advantage gained by the group that performed the 6-month supervised nonaggravating exercise program at 1-year follow-up . They did , however , have fewer days off work The professional literature contains relatively few r and omized-control studies that have assessed the efficacy of physical therapy approaches to the management of patients with chronic low back pain ( CLBP ) .  The purpose s of this study were : 1 ) to investigate the effects of physical agents , joint manipulation , low-tech exercise , and high-tech exercise on objective measures of CLBP ; 2 ) to track the length of CLBP relief ; and 3 ) to determine treatment cost-effectiveness .  Two-hundred-fifty subjects ( 68 females , 182 males ; ages 34 - 51 years ) with CLBP following an L5 laminectomy  were r and omly assigned into five separate groups for a treatment period of 8 weeks . Chronic low back pain status was measured by modified-modified Schober , Cybex Liftask , and Oswestry procedures . Results revealed that : 1 ) only low-tech and high-tech exercise produced significant improvements ( p < .05 ) in CLBP , 2 ) the mean period of CLBP relief ranged from 1.6 weeks ( control ) to 91.4 weeks ( low-tech exercise ) , and 3 ) low-tech exercise was most cost-effective . It was concluded that : 1 ) low-tech and high-tech exercise were the only effective treatments for CLBP , 2 ) low-tech exercise produced the longest period of CLBP relief , and 3 ) low-tech exercise was the most cost-effective form of treatment . Clinical ly , low-tech exercise may be the treatment method of choice for the effective management of chronic low back pain Study Design . Cost-effectiveness analysis alongside a factorial r and omized controlled trial . Objective . To assess the cost-effectiveness of a rehabilitation program and /or an education booklet each compared with usual care for the postoperative management of patients undergoing discectomy or lateral nerve root decompression surgery . Summary of Background Data . There is little knowledge about the cost-effectiveness of postoperative management of patients after spinal surgery . Methods . A total of 338 patients were recruited into the study between June 2005 and March 2009 . Patients were r and omized to rehabilitation only , booklet only , rehabilitation plus booklet , or usual care only . Interactions between booklet and rehabilitation were nonsignificant ; hence , we compare booklet versus no booklet and rehabilitation versus no rehabilitation . We adopt an English National Health Service and personal social services perspective . Data on outcomes and costs are based on patient level data from the trial . A 1-year time horizon was used . Outcomes were measured in terms of quality -adjusted life years . Health-related quality of life was reported by patients using the EuroQol-5D ( EQ-5D ) . A comprehensive range of health service contacts were included in the cost analysis . Results . There were no significant differences in costs or outcomes associated with either intervention . Mean incremental costs and mean quality -adjusted life years gained per patient of booklet versus no booklet were −£87 ( 95 % CI : −£1221 to £ 1047 ) and −0.023 ( 95 % CI : −0.068 to 0.023 ) , respectively . Figures for rehabilitation versus no rehabilitation were £ 160 ( 95 % CI : −£984 to £ 1304 ) and 0.002 ( 95 % CI : −0.044 to 0.048 ) , respectively . Neither intervention was cost-effective when compared with the threshold range commonly used to judge whether or not an intervention is cost-effective in the English National Health Service . Conclusion . Cost-effectiveness evidence does not support use of booklet over no booklet or rehabilitation over no rehabilitation for the postoperative management of patients after spinal surgery This paper proposes a new method for planning r and omized clinical trials . This method is especially suited to comparison of a best st and ard or control treatment with an experimental treatment .  Patients are allocated into two groups by a r and om or chance mechanism . Patients in the first group receive st and ard treatment ; those in the second group are asked if they will accept the experimental therapy ; if they decline , they receive the best st and ard treatment . In the analyses of results , all those in the second group , regardless of treatment , are compared with those in the first group . Any loss of statistical efficiency can be overcome by increased numbers . This experimental plan is indeed a r and omized clinical trial and has the advantage that , before providing consent , a patient will know whether an experimental treatment is to be used Study Design . A prospect i ve r and omized controlled trial of exercise therapy in patients who underwent microdiscectomy for prolapsed lumbar intervertebral disc . Results of a pilot study are presented . Objective . To determine the effects of a postoperative exercise program on pain , disability , psychological status , and spinal function . Summary of Background Data . Microdiscectomy is often used successfully to treat prolapsed lumbar intervertebral disc . However , some patients do not have a good outcome and many continue to have low back pain . The reasons for this are unclear but impairment of back muscle function due to months of inactivity before surgery may be a contributing factor . A postoperative exercise program may improve outcome in such patients . Methods . Twenty patients who underwent lumbar microdiscectomy  were r and omized into EXERCISE and CONTROL groups . After surgery , all patients received normal postoperative care that included advice from a physiotherapist about exercise and a return to normal activities . Six weeks after surgery , patients in the EXERCISE group undertook a 4-week exercise program that concentrated on improving strength and endurance of the back and abdominal muscles and mobility of the spine and hips . Assessment s of spinal function were performed in all patients during the week before surgery and at 6 , 10 , 26 , and 52 weeks after . The assessment included measures of posture , hip and lumbar mobility , back muscle endurance capacity and electromyographic measures of back muscle fatigue . On each occasion , patients completed question naires inquiring about pain , disability and psychological status . Results . Surgery improved pain , disability , back muscle endurance capacity and hip and lumbar mobility in both groups of patients . After the exercise program , the EXERCISE group showed further improvements in these measures and also in electromyographic measures of back muscle fatigability . All these improvements were maintained 12 months after surgery . The only further improvement showed by the CONTROL group between 6 and 52 weeks was an increase in back muscle endurance capacity . Conclusion . A 4-week postoperative exercise program can improve pain , disability , and spinal function in patients who undergo microdiscectomy Study Design . A prospect i ve , r and omized , and controlled study was conducted . Objectives . To evaluate two training programs , both of which started immediately after lumbar discectomy . Summary of Background Data . In previous studies , patients began physiotherapy between 4 weeks and 60 months after surgery . No studies have been conducted to evaluate a physiotherapy program that begins immediately after surgery . Method . Twenty‐six patients were treated according to an early active training program . Twenty‐six patients were treated with a traditional , less active training program ( control group ) . All patients were examined immediately before and after surgery and 3 , 6 , 12 , and 52 weeks after surgery by an unbiased observer . Two years after surgery , patients completed a question naire . Range of motion of the lumbar spine and straight leg raising were measured . Pain intensity and location was measured by a visual analog scale . The duration of sick leave was documented . Results . Six and 12 weeks after surgery , patients with dominating residual leg pain had significantly less intense pain in the early active training group than those in the control group ( P < 0.05 ) . Twelve weeks after surgery , range of motion of the lumbar spine was significantly more increased in the early active training group ( P < 0.01 ) . One year after surgery , there was no significant difference between the groups regarding the duration of sick leave , results in a positive straight leg raising , or pain intensity . Twenty‐two ( 88 % ) patients in the early active training group and 16 ( 67 % ) in the control group were satisfied with the treatment outcome 2 years after surgery ( P < 0.10 ) . Conclusions . Patients rehabilitated according to the early active training program had a better short‐term outcome of objective values . At 2 years ' follow‐up , more patients were satisfied with the result of the operation . The early active treatment program is recommended OBJECTIVE To determine the effects of lumbar extension exercise on strength , disability index , and pain scores in patients after lumbar discectomy surgery . DESIGN Prospect i ve comparative study . SUBJECTS Forty patients experiencing a herniated disc at lumbar levels were divided into 4 subgroups for different training frequencies : twice/week ( group 1 ) , once/week ( group 2 ) , once/2 weeks ( group 3 ) , and no training ( control ) . METHODS After completing the initial 12-week training , all subjects participated in a 12-week follow-up training . RESULTS Groups 1 and 2 showed significant increases in lumbar extension strength ( 26 Nm and 7 Nm , respectively ) , while group 3 and the control group showed significant decreases in lumbar extension strength . Groups 1 and 2 showed significant decreases in disability index ( 1.4 and 0.8 Oswestry Disability Index points , respectively ) , and group 1 showed significant decreases in back and leg pain scores ( both 0.5 units on a 10-cm visual analog scale ) . CONCLUSION Lumbar extension strength and disability index improve with training frequencies of once and twice per week , while back and leg pain improve with a training frequency of twice per week . The clinical importance of these improvements is question able , as the scores were already very low after the discectomy and the magnitude of absolute improvements were small To comprehend the results of a r and omised controlled trial ( RCT ) , readers must underst and its design , conduct , analysis , and interpretation . That goal can be achieved only through total transparency from authors . Despite several decades of educational efforts , the reporting of RCTs needs improvement . Investigators and editors developed the original CONSORT ( Consoli date d St and ards of Reporting Trials ) statement to help authors improve reporting by use of a checklist and flow diagram . The revised CONSORT statement presented here incorporates new evidence and addresses some criticisms of the original statement . The checklist items pertain to the content of the Title , Abstract , Introduction , Methods , Results , and Discussion . The revised checklist includes 22 items selected because empirical evidence indicates that not reporting this information is associated with biased estimates of treatment effect , or because the information is essential to judge the reliability or relevance of the findings . We intended the flow diagram to depict the passage of participants through an RCT . The revised flow diagram depicts information from four stages of a trial ( enrollment , intervention allocation , follow- up , and analysis ) . The diagram explicitly shows the number of participants , for each intervention group , included in the primary data analysis . Inclusion of these numbers allows the reader to judge whether the authors have done an intention- to-treat analysis . In sum , the CONSORT statement is intended to improve the reporting of an RCT , enabling readers to underst and a trial 's conduct and to assess the validity of its results BACKGROUND Magnetic resonance imaging ( MRI ) is frequently performed during follow-up in patients with known lumbar-disk herniation and persistent symptoms of sciatica . The association between findings on MRI and clinical outcome is controversial . METHODS We studied 283 patients in a r and omized trial comparing surgery and prolonged conservative care for sciatica and lumbar-disk herniation . Patients underwent MRI at baseline and after 1 year . We used a 4-point scale to assess disk herniation on  MRI  , ranging from 1 for " definitely present " to 4 for " definitely absent . " A favorable clinical outcome was defined as complete or nearly complete disappearance of symptoms at 1 year . We compared proportions of patients with a favorable outcome among those with a definite absence of disk herniation and those with a definite , probable , or possible presence of disk herniation at 1 year . The area under the receiver-operating-characteristic ( ROC ) curve was used to assess the prognostic accuracy of the 4-point scores regarding a favorable or unfavorable outcome , with 1 indicating perfect discriminatory value and 0.5 or less indicating no discriminatory value . RESULTS At 1 year , 84 % of the patients reported having a favorable outcome . Disk herniation was visible in 35 % with a favorable outcome and in 33 % with an unfavorable outcome ( P=0.70 ) . A favorable outcome was reported in 85 % of patients with disk herniation and 83 % without disk herniation ( P=0.70 ) .  MRI assessment of disk herniation did not distinguish between patients with a favorable outcome and those with an unfavorable outcome ( area under ROC curve , 0.48 ) . CONCLUSIONS MRI performed at 1-year follow-up in patients who had been treated for sciatica and lumbar-disk herniation did not distinguish between those with a favorable outcome and those with an unfavorable outcome . ( Funded by the Netherl and s Organization for Health Research and Development and the Hoelen Foundation ; Controlled Clinical Trials number , IS RCT N26872154 . ) Study Design . This was a multicenter , factorial , r and omized , controlled trial on the postoperative management of spinal surgery patients , with r and omization stratified by surgeon and operative procedure . Objective . This study sought to determine whether the functional outcome of two common spinal operations could be improved by a program of postoperative rehabilitation that combines professional support and advice with grade d active exercise commencing 6 weeks after surgery and /or an educational booklet based on evidence -based messages and advice received at discharge from hospital , each compared with usual care . Summary of Background Data . Surgical interventions on the spine are increasing , and while surgery for spinal stenosis and disc prolapse have been shown to be superior to conservative management , functional outcome , and patient satisfaction are not optimal . Methods . The study compared the effectiveness of a rehabilitation program and an education booklet for the postoperative management of patients undergoing discectomy or lateral nerve root decompression surgery , each compared with “ usual care ” using a 2 × 2 factorial design , r and omizing patient to four groups ; rehabilitation-only , booklet-only  , rehabilitation-plus-booklet , and usual care only . The primary outcome measure was the Oswestry Disability Index ( ODI ) at 12 months , with secondary outcomes including visual analog scale measures of back and leg pain . Results . Three hundred thirty-eight patients were recruited into the study and measurements were obtained preoperatively and then repeated at 6 weeks , 3 , 6 , 9 and 12 months postoperatively . Twelve months postoperatively the observed effect of rehabilitation  on ODI was −2.7 ( 95 % CI : −6.8 to 1.5 ) and the effect of booklet was 2.7 ( 95 % CI : −1.5 to 6.9 ) . Conclusion . This study found that neither intervention had a significant impact on long-term outcome Background Restoration of physical function following lumbar microdiskectomy may be influenced by the postoperative care provided . Objective The purpose of this study was to examine the effectiveness of a new interventional protocol to improve functional performance in patients who have undergone a single-level lumbar microdiskectomy . Setting The study was conducted in physical therapy outpatient clinics . Design and Participants Ninety-eight participants ( 53 male , 45 female ) who had undergone a single-level lumbar microdiskectomy were r and omly allocated to receive education only or exercise and education . Intervention and Measurements The exercise intervention consisted of a 12-week periodized program of back extensor strength ( force-generating capacity ) and endurance training and mat and upright therapeutic exercises . The Oswestry Disability Index ( ODI ) and physical measures of functional performance were tested 4 to 6 weeks postsurgery and 12 weeks later , following completion of the intervention program . Because some participants sought physical therapy outside of the study , postintervention scores were analyzed for both an as-r and omized ( 2-group ) design and an as-treated ( 3-group ) design . Results In the 2-group analyses , exercise and education result ed in a greater reduction in ODI scores and a greater improvement in distance walked . In the 3-group analyses , post hoc comparisons showed a significantly greater reduction in ODI scores following exercise and education compared with the education-only and usual physical therapy groups . Limitations The limitations of this study include a lack of adherence to group assignment , disproportionate therapist contact time among treatment groups , and multiple use of univariate analyses . Conclusions An intensive , progressive exercise program combined with education reduces disability and improves function in patients who have undergone a single-level lumbar microdiskectomy
BACKGROUND Several rehabilitation programmes are available for individuals after lumbar disc surgery .
OBJECTIVES To determine whether  active rehabilitation  after lumbar disc surgery is more effective than no treatment , and to describe which type of  active rehabilitation  is most effective .
Active rehabilitation that starts immediately postsurgery.2 .
C. Specific intervention in addition to active rehabilitation versus active rehabilitation alone .