Surgery Has Superior Outcome in Treatment for Lumbar Disc HerniationWhen a patient has a ruptured lumbar disc, which is in the lower part of the back, there are a few options for treatment. They boil down to surgical or nonoperative treatments overall. There has been a lot of debate over which approach is better and several studies have looked at the various techniques and patient outcomes.
The authors of this article added to the bank of information by undertaking a four-year study that looked at the results of surgery versus nonoperative treatment for lumbar disc herniations. Researchers recruited 501 patients who were randomized to the trial and 743 who would be observed only. To qualify for the study, the patients had to have back pain for at least six weeks, have an obvious disc herniation, and be eligible for surgery. They were then offered to be included in the trial or in the observation group. If patients were randomized or chose nonoperative treatment, they had either injections to manage the inflammation and pain, activity restrictions, or restricted medications, narcotics for the pain.
To assess the patients, researchers used the Bodily Pain (BP) and Physical Function (PF) scales and a version of the Oswestry Disability Index, at six weeks, three months, six months, and every year following. The researchers also looked how the patient reported their status, work ability, and satisfaction with the outcome.
In the randomized group, 245 patients underwent surgery (57 percent by the end of year one and 59 percent by the end of year four) and 256 had nonoperative treatment. In the nonoperative group, 41 percent ended up having surgery by the end of year one and 45 percent by the end of year four. The numbers were similar in the observational group. Among the 743 patients, 521 chose to have surgery and 95 percent of them had it by the end of year one. However, if they hadn't had it by then, they didn't have surgery later on, unlike some in the randomized groups.
When looking at the characteristics of the patients in the randomized group and those in the observational group, the researchers found that those who chose to be in the observational group were generally in more pain, felt the pain was worsening and preferred surgery than those who chose to be in the randomized group. In the randomized group, the patients were younger, more likely to be unemployed or on sick leave, more likely to be receiving compensation, have higher body mass index, more pain and more dissatisfaction with treatment.
Patients who had surgery did have the risk of complications associated with the procedures. There was also a difference between the patients who had surgery from the randomized group and those who did from the observational group. The randomized group tended to have lightly longer operating times and slightly more blood loss during surgery. Other issues, such as a need for repeat surgeries didn't show a difference between the two groups.
The authors wrote that there was an issue of nonadherence, patients not sticking to their treatments, in both groups. Some patients waited before having surgery while others who weren't going to have surgery chose to anyway and the other way around. Because of this, it can be difficult for researchers to determine the "intent" of whether treatment would be effective or not. That being said, overall, the results did show that surgery did show a better outcome for patients in the end.
James N. Weinstein, DO, MS, et al. Surgical Versus Nonoperative Treatment for Lumbar Disc Herniation. In Spine.. December 1, 2008. Vol. 33. No. 25. Pp. 2789-2800.
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