Comparison of Chemonucleolysis and Discectomy in the Management of Lumbar Disc Herniation: A Comprehensive Systematic Review and Meta-analysis

Introduction: Lumbar disc herniation (LDH) represents a significant cause of pain and physical impairment, negatively impacting the quality of life, and burdening healthcare systems. Despite numerous treatment strategies, optimal management remains a subject of debate. This meta-analysis aims to compare the efficacy and economic impact of chemonucleolysis (CN) and discectomy in the management of LDH

Methods: An extensive search of Embase, PubMed, and Cochrane databases yielded 391 records. Following strict inclusion and exclusion criteria, twenty-one studies suitable for a comparative analysis between CN and discectomy were included. This selection was based on patient improvement, including pain scores, complications, and differences in cost and surgery time. Statistical analysis was performed using Review Manager 5.4.1. Heterogeneity was examined with I2 statistics. Risk of bias was assessed using RoB-2 and ROBINS-I

Results: A total of 2436 patients were included in this study. Among them, 1,121 patients (46%) underwent discectomy, while 1,315 patients (54%) received the CN approach. Our analysis revealed that discectomy had a significantly higher improvement rate compared with chymopapain CN (OR = 0.45; 95% CI 0.23, 0.88) and non-chymopapain CN (OR = 0.61; 95% CI 0.38, 0.97). A non-significant inclination towards complication rates was observed with chymopapain CN (OR = 1.90; 95% CI 0.68, 5.29). Notably, CN was associated with a considerable cost reduction (SMD = 7.11; 95% CI -11.37, -2.85) and a shorter surgical time (MD = -53.54; 95% CI -57.91, -49.17) compared with discectomy

Conclusion : The evidence synthesized in this meta-analysis suggests superior clinical outcomes for discectomy compared to CN in managing LDH. However, CN demonstrated a notable advantage in cost-efficiency and operative time, marking it as a potentially preferable option in resource-constrained settings. Nonetheless, more randomized clinical trials and prospective studies must confirm these findings