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Is Surgery Necessary for Lumbar Disc Herniation?
Surgical and nonsurgical approaches to treatment have similar long-term outcomes.
Although many patients undergo surgery for lumbar disc herniation, symptoms of disk herniation often improve with observation alone. These researchers conducted both a randomized trial of diskectomy vs. nonoperative therapy and an observational study involving subjects who declined randomization.
In the randomized trial, 472 patients with lumbar radicular pain that correlated with disk herniation on imaging were assigned to standard lumbar diskectomy or individualized nonoperative care (including active physical therapy, home exercise, and analgesics); at baseline, 40% of patients had motor weakness, and 47% had sensory changes. Of 232 patients randomized to surgery, 92 (40%) did not have surgery, mostly because they improved considerably before surgery could occur; of 240 randomized to nonoperative treatment, 107 (45%) had surgery, mostly to address worsening symptoms. Both groups improved substantially during 2 years of follow-up; in intent-to-treat analyses, no significant differences were found between groups in the primary outcomes — standardized assessments of pain, physical function, and disability. Some secondary outcomes favored surgery, but these differences were clinically unimportant.
In the observational study, 743 patients meeting the same inclusion criteria who declined randomization (of whom 528 chose surgery) were assessed over a 2-year period. Both groups improved substantially; those who had surgery reported significantly more improvement in pain, physical function, and disability. Subjects who chose surgery were younger and had worse symptoms and physical function at baseline.
Comment: The high crossover rate in the first study and the observational nature of the second diminish the clinical value of these results, although they do support patient choice in treating disk herniation. An editorialist suggests that a randomized trial with a sham surgery arm would be ethically justified, to control for the placebo effects that may influence outcomes from surgery.
— Thomas L. Schwenk, MD
Published in Journal Watch General Medicine November 28, 2006
Citation(s):
Weinstein JN et al. Surgical vs nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT): A randomized trial. JAMA 2006 Nov 22/29; 296:2441-50.
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Weinstein JN et al. Surgical vs nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 2006 Nov 22/29; 296:2451-9.
- Original article (Subscription may be required)
- Medline abstract (Free)
Flum DR. Interpreting surgical trials with subjective outcomes: Avoiding unSPORTsmanlike conduct. JAMA 2006 Nov 22/29; 296:2483-5.
- Original article (Subscription may be required)
- Medline abstract (Free)