***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Study Design . This study evaluated clinical and magnetic resonance imaging differences of patients treated surgically for lumbar disc herniation . Clinical follow-up and magnetic resonance imaging evaluation of epidural fibrosis were used to assess patient outcome . Objectives . The purpose of this study was to evaluate the difference in clinical outcome with either free-fat graft , Golfoam , or no interposition membrane placed in the laminectomy defect after nerve root decompression . Summary of Background Data . Epidural fibrosis has been considered a cause of recurrent symptoms after lumbar laminectomy , and numerous material s have been evaluated for prophylaxis of the “ laminectomy membrane . ” These have been mainly histologic and animal studies with no data correlating clinical symptoms and postoperative epidural scar formation . Methods . One hundred fifty-six patients who were treated surgically for lumbar disc herniation were r and omly assigned to one of three groups and followed prospect ively for at least 1 year . Thirty-three of these patients were received magnetic resonance imaging evaluations after 6 months by an idependent radiologist who grade d the amount of epidural scar formation . The patients were assessed at 1 year and given a rating of excellent , good , fair , or poor , and the scar was grade d as none , minimal , or moderate . Results . Although 97 % of all patients improved , 83 % were rated excellent or good . There were no statistical differences between the three groups clinical ly and radiographically . Patients with workers compensation had a statistically significant lower success rate ( P < 0.001 ) . Conclusions . Clinical outcome after lumbar disc surgery does not correlate with the use or type of interposition membrane used to prevent epidural fibrosis Abstract This single-blind r and omised clinical trial compared osteopathic manipulative treatment with chemonucleolysis ( used as a control of known efficacy ) for symptomatic lumbar disc herniation . Forty patients with sciatica due to this diagnosis ( confirmed by imaging ) were treated either by chemonucleolysis or manipulation . Outcomes ( leg pain , back pain and self-reported disability ) were measured at 2 weeks , 6 weeks and 12 months . The mean values for all outcomes improved in both groups . By 12 months , there was no statistically significant difference in outcome between the treatments , but manipulation produced a statistically significant greater improvement for back pain and disability in the first few weeks . A similar number from both groups required additional orthopaedic intervention ; there were no serious complications . Crude cost analysis suggested an overall financial advantage from manipulation . Because osteopathic manipulation produced a 12-month outcome that was equivalent to chemonucleolysis , it can be considered as an option for the treatment of  symptomatic lumbar disc herniation  , at least in the absence of clear indications for surgery . Further study into the value of manipulation at a more acute stage is warranted OBJECT The authors of clinical studies have demonstrated a significant association between the presence of extensive post-lumbar discectomy peridural scar formation and the recurrence of  low-back and radicular pain .  Low-dose perioperative radiotherapy has been demonstrated to inhibit peridural fibrosis after laminectomy in animal models . The present study was design ed to evaluate the clinical efficacy of preoperative irradiation in patients with failed-back surgery syndrome due to peridural fibrosis who underwent reexploration and nerve root decompression . METHODS Ten patients with symptomatic post-discectomy peridural fibrosis were r and omized . Half of the patients underwent 700-cGy external-beam irradiation to the operative site 24 hours prior to reexploration and decompressive treatment of their symptomatic nerve root(s ) ( treatment group ) and the other half underwent reexploration and decompressive treatment without preoperative irradiation ( control group ) . All patients underwent simulated irradiation so neither patient nor surgeon was aware of the patient 's group . In all patients the antiadhesion product ADCON-L was placed over the affected nerve root at the time of surgery . Clinical outcome was assessed using the American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Section Lumbar Disc Herniation Study Question naire at baseline , 6 weeks , 3 months , and 1 year follow up . Five men and five women ( mean age 42 years ) underwent r and omization and surgery . Three patients underwent reexploration at L4 - 5 , four at L5-S1 , and three at both levels . No complication was associated with irradiation , and no new neurological deficits occurred . At 1-year follow-up examination , three irradiation-treated patients were pain free and two experienced improvement . In the control group , three patients experienced improved pain relief and two were unchanged . There was a trend toward better outcome at 1 year in the radiotherapy-treated group ( p = 0.056 ) . CONCLUSIONS Preoperative low-dose external-beam irradiation improved clinical outcomes after reexploration and decompression of nerve roots affected by postlaminectomy peridural fibrosis causing radicular pain . The addition of preoperative irradiation may improve outcome in patients who undergo reoperation for recurrent radicular pain associated with a significant amount of peridural fibrosis , particularly now that no antiadhesion product is available for clinical use Objective : To determine the efficacy of epidural corticosteroid injections for sciatica . Methods : Three epidural injections ( two day intervals ) of 2 ml prednisolone acetate ( 50 mg ) or 2 ml isotonic saline were administered to patients with sciatica presumably due to a disk herniation lasting 15–180 days .  Self evaluation was the main judgment criterion at day 20 . Patients who recovered or showed marked improvement were considered as success . Pain measured by VAS , the SLR test , Schober ’s test , Dallas pain question naire , and the Rol and -Morris index were evaluated at days 0 , 5 , 20 , and 35 . Only analgesics were authorised , patients requiring non-steroidal anti-inflammatory drugs ( NSAIDs ) before day 20 were considered as failure . Results : 42 patients were included in the control group ( CG ) , 43 in the steroid group ( SG ) . On an intention to treat analysis 15/42 ( 36 % ) in the CG and 22/43 ( 51 % ) in the SG ( p=0.15 ) were considered as success ( difference 15.5 % , 95 % CI ( −5.4 to 36.3 ) ) . Among the 48 failures , 14 patients ( 6 CG , 8 SG ) required NSAIDs , 3 ( 2 CG , 1 SG ) required surgery , and 7 ( 3 CG , 4 SG ) other treatments . On analysis according to protocol , in 74 remaining patients 12/35 ( 34 % ) in the CG and 22/39 ( 56 % ) in the SG ( p=0.057 ) were considered as success ( difference 22.1 % , 95 % CI ( 0.0 to 44.2 ) ) . For all secondary end points intragroup improvement with time was significant , but intergroup differences were not . Conclusion : The efficacy of isotonic saline administered epidurally for sciatica can not be excluded , but epidural steroid injections provide no additional improvement 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 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 The management of sciatica due to lumbar nerve root compromise remains controversial , probably because few well-controlled studies of conservative management have been performed . This preliminary study assesses the efficacy of epidural injections of 80 mg triamcinolone acetonide plus 0.5 % procaine hydrochloride in saline , administered via the caudal route , in a double-blind , placebo controlled trial with 1 year follow- 
    Output:
    
For overall recovery as the outcome , compared with inactive control or conventional care , there was a statistically significant improvement following disc surgery , epidural injections , nonopioid analgesia , manipulation , and acupuncture .
Traction , percutaneous discectomy , and exercise therapy were significantly inferior to epidural injections or surgery .
For pain as the outcome , epidural injections and biological agents were significantly better than inactive control , but similar findings for disc surgery were not statistically significant .
Biological agents were significantly better for pain reduction than bed rest , nonopioids , and opioids .
Opioids , education/advice alone , bed rest , and percutaneous discectomy were inferior to most other treatment strategies ; although these findings represented large effects , they were statistically equivocal .
The findings support the effectiveness of nonopioid medication , epidural injections , and disc surgery .
They also suggest that spinal manipulation , acupuncture , and experimental treatments , such as anti-inflammatory biological agents , may be considered .
The findings do not provide support for the effectiveness of opioid analgesia , bed rest , exercise therapy , education/advice  ( when used alone ) ,  percutaneous discectomy  , or traction .